Basic Information
| Provider Information | |||||||||
| NPI: | 1578753950 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARA | ||||||||
| FirstName: | ELISA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | CADC-CAS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LARA | ||||||||
| OtherFirstName: | ELISA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | CAS | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2087 | ||||||||
| Address2: | |||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953440087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093816800 | ||||||||
| FaxNumber: | 2093853174 | ||||||||
| Practice Location | |||||||||
| Address1: | 40 W G ST STE C | ||||||||
| Address2: | |||||||||
| City: | LOS BANOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936353657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097106100 | ||||||||
| FaxNumber: | 2098272009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2007 | ||||||||
| LastUpdateDate: | 06/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | C13861214 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.