Healthcare Provider Details

I. General information

NPI: 1497809347
Provider Name (Legal Business Name): MRS. MARIA LARA WYATT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARIA ISABEL LARA

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

253 E ROSS RD
EL CENTRO CA
92243-9797
US

IV. Provider business mailing address

253 E ROSS RD
EL CENTRO CA
92243-9797
US

V. Phone/Fax

Practice location:
  • Phone: 760-312-5500
  • Fax:
Mailing address:
  • Phone: 760-312-5500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: