MEDICARE: LARA CARPENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker

General Provider Information

NPI Number	:	1699824383
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARA CARPENTER

Provider Business Mailing Address
First Line	:	3270 SUNTREE BLVD STE 100
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32940-7532
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3270 SUNTREE BLVD
Second Line	:	SUITE 100
City	:	MELBOURNE
State	:	FL
Zip	:	32940-7530
Country	:	US
Telephone Number	:	321-752-3170
Fax Number	:	321-752-3179

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/10/2007
Last Update Date	:	07/08/2007

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Directions to “ LARA CARPENTER ” Practice Location

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