Provider Demographics
NPI:1053610022
Name:LARA, MARIA ESTELA
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:ESTELA
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 1:614 TULLY RD
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95111-1048
Mailing Address - Country:US
Mailing Address - Phone:408-977-1591
Mailing Address - Fax:408-977-1136
Practice Address - Street 1:614 TULLY RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95111-1048
Practice Address - Country:US
Practice Address - Phone:408-977-1591
Practice Address - Fax:408-977-1136
Is Sole Proprietor?:No
Enumeration Date:2011-03-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAN9979486101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)