Provider Demographics
NPI:1487320396
Name:LARA, ELOISA (PT)
Entity type:Individual
Prefix:
First Name:ELOISA
Middle Name:
Last Name:LARA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 CREST ST APT 117
Mailing Address - Street 2:
Mailing Address - City:WESTWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-3169
Mailing Address - Country:US
Mailing Address - Phone:201-449-4779
Mailing Address - Fax:
Practice Address - Street 1:28B INDIAN ROCK
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:NY
Practice Address - Zip Code:10901-4907
Practice Address - Country:US
Practice Address - Phone:845-368-2180
Practice Address - Fax:845-368-2187
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047411-01225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist