Provider Demographics
NPI:1417771833
Name:ANDERSON, LARA C
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:C
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 MASON ST STE 300
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-4483
Mailing Address - Country:US
Mailing Address - Phone:707-463-3300
Mailing Address - Fax:707-463-3318
Practice Address - Street 1:169 MASON ST STE 300
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-4483
Practice Address - Country:US
Practice Address - Phone:707-463-3300
Practice Address - Fax:707-463-3318
Is Sole Proprietor?:No
Enumeration Date:2024-11-12
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW1236541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical