Provider Demographics
NPI:1982904520
Name:LARA, JUAN JOSE (MFT)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:JOSE
Last Name:LARA
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16039 NORDHOFF ST
Mailing Address - Street 2:
Mailing Address - City:NORTH HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91343-3041
Mailing Address - Country:US
Mailing Address - Phone:818-720-8293
Mailing Address - Fax:
Practice Address - Street 1:901 N PACIFIC COAST HWY
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-2162
Practice Address - Country:US
Practice Address - Phone:310-906-6752
Practice Address - Fax:310-316-4209
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-29
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC41135106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist