Provider Demographics
NPI:1740345529
Name:EMBRY, LARA E (PHD)
Entity type:Individual
Prefix:DR
First Name:LARA
Middle Name:E
Last Name:EMBRY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3256 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35205-1451
Mailing Address - Country:US
Mailing Address - Phone:205-538-5823
Mailing Address - Fax:
Practice Address - Street 1:3256 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35205-1451
Practice Address - Country:US
Practice Address - Phone:205-538-5823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 7390103G00000X, 103TC0700X, 103TH0100X
AL1899103TC2200X, 103TC0700X, 103TF0000X, 103TF0200X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU3809ZMedicare ID - Type Unspecified