Provider Demographics
NPI:1154726024
Name:MUNDEN-JOHNSON, LARA (LICSW)
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:
Last Name:MUNDEN-JOHNSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:LARA
Other - Middle Name:
Other - Last Name:MUNDEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICSW
Mailing Address - Street 1:145 S WORTHEN ST
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-3081
Mailing Address - Country:US
Mailing Address - Phone:509-662-6761
Mailing Address - Fax:509-663-3182
Practice Address - Street 1:5301 TIETON DR
Practice Address - Street 2:STE C
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908-3479
Practice Address - Country:US
Practice Address - Phone:509-662-6761
Practice Address - Fax:509-663-3182
Is Sole Proprietor?:No
Enumeration Date:2014-11-04
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW603326061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical