Provider Demographics
NPI:1306064985
Name:LARA, RAUL (MFT)
Entity type:Individual
Prefix:MR
First Name:RAUL
Middle Name:
Last Name:LARA
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22030 SHERMAN WAY STE 316
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91303-2206
Mailing Address - Country:US
Mailing Address - Phone:818-436-2805
Mailing Address - Fax:818-436-2810
Practice Address - Street 1:22030 SHERMAN WAY STE 316
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91303-2206
Practice Address - Country:US
Practice Address - Phone:818-436-2805
Practice Address - Fax:818-436-2810
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-21
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40652106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist