Provider Demographics
NPI:1689408700
Name:LARA, GABRIEL MICHAEL (CATC III)
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:MICHAEL
Last Name:LARA
Suffix:
Gender:M
Credentials:CATC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1242 N GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-1426
Mailing Address - Country:US
Mailing Address - Phone:626-678-4830
Mailing Address - Fax:
Practice Address - Street 1:1242 N GILBERT ST
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-1426
Practice Address - Country:US
Practice Address - Phone:626-678-4830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-30
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty