Provider Demographics
NPI:1598816845
Name:HEAD, LARA ELIZABETH (RPT)
Entity type:Individual
Prefix:MS
First Name:LARA
Middle Name:ELIZABETH
Last Name:HEAD
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:MS
Other - First Name:LARA
Other - Middle Name:ELIZABETH
Other - Last Name:HEAD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPT
Mailing Address - Street 1:2511 FAIRLANE DR STE C100
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36116-1649
Mailing Address - Country:US
Mailing Address - Phone:334-215-0034
Mailing Address - Fax:
Practice Address - Street 1:2511 FAIRLANE DR STE C100
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-1649
Practice Address - Country:US
Practice Address - Phone:334-215-0034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2393225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist