Provider Demographics
NPI:1427627462
Name:LARA, KRISTEN M (MA, LAC)
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:M
Last Name:LARA
Suffix:
Gender:F
Credentials:MA, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 S MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:CEDAR GROVE
Mailing Address - State:NJ
Mailing Address - Zip Code:07009-2118
Mailing Address - Country:US
Mailing Address - Phone:201-207-8106
Mailing Address - Fax:
Practice Address - Street 1:600 GETTY AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-2161
Practice Address - Country:US
Practice Address - Phone:201-665-3066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00552200101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor