Provider Demographics
NPI:1265587208
Name:INSERTO, LARA JANE RAQUIN (RPT)
Entity type:Individual
Prefix:
First Name:LARA JANE
Middle Name:RAQUIN
Last Name:INSERTO
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2760 PEARCE PT
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-9047
Mailing Address - Country:US
Mailing Address - Phone:812-490-8586
Mailing Address - Fax:
Practice Address - Street 1:4088 FRAME RD
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-2258
Practice Address - Country:US
Practice Address - Phone:812-853-9567
Practice Address - Fax:812-853-1691
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05008146A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist