Basic Information
Provider Information | |||||||||
NPI: | 1457874182 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LAITY | ||||||||
FirstName: | LARA | ||||||||
MiddleName: | C | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS, LMFT 125458 | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2178 JOHNSON AVE | ||||||||
Address2: |   | ||||||||
City: | SAN LUIS OBISPO | ||||||||
State: | CA | ||||||||
PostalCode: | 934014535 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8054616060 | ||||||||
FaxNumber: | 8054616061 | ||||||||
Practice Location | |||||||||
Address1: | 5575 HOSPITAL DRIVE | ||||||||
Address2: |   | ||||||||
City: | ATASCADERO | ||||||||
State: | CA | ||||||||
PostalCode: | 93422 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8054616060 | ||||||||
FaxNumber: | 8054616061 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/25/2017 | ||||||||
LastUpdateDate: | 04/11/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/11/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | IMG93901 | CA | N |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   | 106H00000X | AMFT93901 | CA | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
No ID Information.