Provider Demographics
NPI:1396488060
Name:LARA BARTOLO, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:LARA BARTOLO
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 1:3705 PO RIVER WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95834-7623
Mailing Address - Country:US
Mailing Address - Phone:916-868-4139
Mailing Address - Fax:
Practice Address - Street 1:3705 PO RIVER WAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95834-7623
Practice Address - Country:US
Practice Address - Phone:916-868-4139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-19
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32492235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist