Provider Demographics
NPI:1194166553
Name:LARA, CARLOS S
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:S
Last Name:LARA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8804 COMMONWEALTH BLVD
Mailing Address - Street 2:
Mailing Address - City:BELLEROSE
Mailing Address - State:NY
Mailing Address - Zip Code:11426-1639
Mailing Address - Country:US
Mailing Address - Phone:914-939-8935
Mailing Address - Fax:718-312-0730
Practice Address - Street 1:8804 COMMONWEALTH BLVD
Practice Address - Street 2:
Practice Address - City:BELLEROSE
Practice Address - State:NY
Practice Address - Zip Code:11426-1639
Practice Address - Country:US
Practice Address - Phone:914-939-8935
Practice Address - Fax:718-312-0730
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-15
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY720810831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical