Basic Information
| Provider Information | |||||||||
| NPI: | 1033843115 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARA | ||||||||
| FirstName: | ALEJANDRA | ||||||||
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| Credential: | M.S., CF-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9501 S I 35 SERVICE RD APT 213 | ||||||||
| Address2: | |||||||||
| City: | MOORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731603141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058857807 | ||||||||
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| Practice Location | |||||||||
| Address1: | 309 SW 59TH ST STE 305 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731098324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053553239 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2022 | ||||||||
| LastUpdateDate: | 07/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | CF487 | OK | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | CF487 | 05 | OK | MEDICAID |