MEDICARE: LARA LYNN SOUTH PHD

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	103TC0700X	Clinical Psychologist	022307	NY
2	103TC0700X	Clinical Psychologist	31523	CA

General Provider Information

NPI Number	:	1851652655
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARA LYNN SOUTH PHD

Provider Business Mailing Address
First Line	:	3553 ATLANTIC AVE STE B
Second Line	:	1154
City	:	LONG BEACH
State	:	CA
Zip	:	90807-5607
Country	:	US
Telephone Number	:	424-470-7768
Fax Number	:

Provider Business Practice Location Address
First Line	:	3553 ATLANTIC AVE STE B
Second Line	:	1154
City	:	LONG BEACH
State	:	CA
Zip	:	90807-5607
Country	:	US
Telephone Number	:	424-470-7768
Fax Number	:

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

Provider Enumeration Date	:	06/07/2012
Last Update Date	:	01/05/2026

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