Provider Demographics
NPI:1740896976
Name:LARA RIVERA, INGRID LISSETTE
Entity type:Individual
Prefix:
First Name:INGRID
Middle Name:LISSETTE
Last Name:LARA RIVERA
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 1:4744 12TH AVE NE APT 311
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-4494
Mailing Address - Country:US
Mailing Address - Phone:707-294-5983
Mailing Address - Fax:
Practice Address - Street 1:2400 NE 95TH ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-2426
Practice Address - Country:US
Practice Address - Phone:206-525-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker