Provider Demographics
NPI:1851668503
Name:GOLD, LARA
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:
Last Name:GOLD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 12TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94103-1297
Mailing Address - Country:US
Mailing Address - Phone:415-905-5050
Mailing Address - Fax:
Practice Address - Street 1:68 12TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-1297
Practice Address - Country:US
Practice Address - Phone:415-905-5050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-23
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1922259548OtherMCE