Healthcare Provider Details

I. General information

NPI: 1053491225
Provider Name (Legal Business Name): LARA ANN FREDA ED.S. SCHOOL PSYCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 07/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9419 W VAN BUREN ST
TOLLESON AZ
85353-2804
US

IV. Provider business mailing address

16429 S 33RD ST
PHOENIX AZ
85048-7845
US

V. Phone/Fax

Practice location:
  • Phone: 623-478-4239
  • Fax:
Mailing address:
  • Phone: 623-478-4239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: