Provider Demographics
NPI:1023739794
Name:DE LARA, CHRISTINE MARIE
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:MARIE
Last Name:DE LARA
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 1:9117 NEWHALL DR APT 15
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-5373
Mailing Address - Country:US
Mailing Address - Phone:619-771-7726
Mailing Address - Fax:
Practice Address - Street 1:811 GRAND AVE STE D
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95838-3466
Practice Address - Country:US
Practice Address - Phone:916-561-6090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-09
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA137186106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator