Basic Information
| Provider Information | |||||||||
| NPI: | 1033426481 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LARA | ||||||||
| FirstName: | LATICIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 609 PROSPECT AVE | ||||||||
| Address2: | APT.#8 | ||||||||
| City: | SOUTH PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910302454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234597131 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3250 WILSHIRE BLVD | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900101577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233613849 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2010 | ||||||||
| LastUpdateDate: | 11/21/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.