Provider Demographics
NPI:1962980920
Name:DE LARA, MARGARET ROSE
Entity type:Individual
Prefix:
First Name:MARGARET
Middle Name:ROSE
Last Name:DE LARA
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 1:1301 PINE AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-3124
Mailing Address - Country:US
Mailing Address - Phone:562-595-1159
Mailing Address - Fax:
Practice Address - Street 1:222 W 6TH ST STE 230
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731
Practice Address - Country:US
Practice Address - Phone:310-833-3135
Practice Address - Fax:310-707-2877
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-01
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT105592106H00000X
CA131230106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty