Provider Demographics
NPI:1881199529
Name:LARA, TRISTAN OSCAR (RBT)
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:OSCAR
Last Name:LARA
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2008 CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32502-5230
Mailing Address - Country:US
Mailing Address - Phone:305-987-8412
Mailing Address - Fax:
Practice Address - Street 1:2008 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32502-5230
Practice Address - Country:US
Practice Address - Phone:305-987-8412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-26
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst