Provider Demographics
NPI:1588271761
Name:LARA, LUIS ENRIQUE (RBT)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:ENRIQUE
Last Name:LARA
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:262 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92570-2001
Mailing Address - Country:US
Mailing Address - Phone:951-210-9773
Mailing Address - Fax:
Practice Address - Street 1:3600 LIME ST STE 612
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-0919
Practice Address - Country:US
Practice Address - Phone:951-210-9773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician