Healthcare Provider Details

I. General information

NPI: 1043946379
Provider Name (Legal Business Name): ROBERTA LARA RADT-1
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2022
Last Update Date: 08/12/2022
Certification Date: 08/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 WEEOT WAY
ARCATA CA
95521-4734
US

IV. Provider business mailing address

1600 WEEOT WAY
ARCATA CA
95521-4734
US

V. Phone/Fax

Practice location:
  • Phone: 707-825-5060
  • Fax:
Mailing address:
  • Phone: 707-825-5060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1367761019
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: