Provider Demographics
NPI:1235968777
Name:LARA, REBECA
Entity type:Individual
Prefix:MISS
First Name:REBECA
Middle Name:
Last Name: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 1:101A MAPLE FOREST CT
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-3958
Mailing Address - Country:US
Mailing Address - Phone:615-500-1465
Mailing Address - Fax:
Practice Address - Street 1:111 IMPERIAL BLVD STE E
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-3400
Practice Address - Country:US
Practice Address - Phone:615-500-1465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician