Provider Demographics
NPI:1265882682
Name:OGBURN, LARA
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:
Last Name:OGBURN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10280 SE 160TH PL
Mailing Address - Street 2:
Mailing Address - City:WHITE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32096-2571
Mailing Address - Country:US
Mailing Address - Phone:386-984-6906
Mailing Address - Fax:
Practice Address - Street 1:10280 SE 160TH PL
Practice Address - Street 2:
Practice Address - City:WHITE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32096-2571
Practice Address - Country:US
Practice Address - Phone:386-984-6906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-16
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018070700Medicaid