Basic Information
| Provider Information | |||||||||
| NPI: | 1558941567 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ERESE | ||||||||
| FirstName: | KATHLEEN LARA | ||||||||
| MiddleName: | ACOSTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5905 SEVERIN DR | ||||||||
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| City: | LA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919423806 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5905 SEVERIN DR | ||||||||
| Address2: | |||||||||
| City: | LA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919423806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195892606 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2021 | ||||||||
| LastUpdateDate: | 04/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 21391 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.