Provider Demographics
NPI:1457874182
Name:LAITY, LARA C (MS, LMFT 125458)
Entity Type:Individual
Prefix:MS
First Name:LARA
Middle Name:C
Last Name:LAITY
Suffix:
Gender:F
Credentials:MS, LMFT 125458
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2178 JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-4535
Mailing Address - Country:US
Mailing Address - Phone:805-461-6060
Mailing Address - Fax:805-461-6061
Practice Address - Street 1:5575 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422
Practice Address - Country:US
Practice Address - Phone:805-461-6060
Practice Address - Fax:805-461-6061
Is Sole Proprietor?:No
Enumeration Date:2017-07-25
Last Update Date:2021-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMG93901106H00000X
CAAMFT93901106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist