Provider Demographics
NPI:1831530948
Name:SKIRVAN, LARA
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:
Last Name:SKIRVAN
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 1:189 STORRS RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD CENTER
Mailing Address - State:CT
Mailing Address - Zip Code:06250-1683
Mailing Address - Country:US
Mailing Address - Phone:860-756-1311
Mailing Address - Fax:
Practice Address - Street 1:189 STORRS RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD CENTER
Practice Address - State:CT
Practice Address - Zip Code:06250-1683
Practice Address - Country:US
Practice Address - Phone:860-756-1311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002044101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional