Provider Demographics
NPI:1851652655
Name:SOUTH, LARA LYNN (PHD)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:LYNN
Last Name:SOUTH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:LARA
Other - Middle Name:LYNN
Other - Last Name:BRABHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1110 N VIRGIL AVE # 154
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029-2016
Mailing Address - Country:US
Mailing Address - Phone:424-470-7768
Mailing Address - Fax:
Practice Address - Street 1:1110 N VIRGIL AVE # 154
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-2016
Practice Address - Country:US
Practice Address - Phone:424-470-7768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-07
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31523103TC0700X
NY022307103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical