Provider Demographics
NPI:1194430744
Name:THOMPSON, LARA K (CCC-SLP)
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:K
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY PT
Mailing Address - State:NY
Mailing Address - Zip Code:11697-2105
Mailing Address - Country:US
Mailing Address - Phone:718-608-4722
Mailing Address - Fax:
Practice Address - Street 1:9807 38TH AVE
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-2133
Practice Address - Country:US
Practice Address - Phone:718-608-4722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist