Provider Demographics
NPI:1972818672
Name:KOLJONEN, LARA JOAN (LAC)
Entity Type:Individual
Prefix:MS
First Name:LARA
Middle Name:JOAN
Last Name:KOLJONEN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-6207
Mailing Address - Country:US
Mailing Address - Phone:619-564-8303
Mailing Address - Fax:619-996-2153
Practice Address - Street 1:2801 4TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-6207
Practice Address - Country:US
Practice Address - Phone:619-564-8303
Practice Address - Fax:619-996-2153
Is Sole Proprietor?:No
Enumeration Date:2010-08-18
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12326171100000X
172M00000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No172M00000XOther Service ProvidersMechanotherapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist