Healthcare Provider Details

I. General information

NPI: 1932920378
Provider Name (Legal Business Name): DINA M LARA SCHOOL PSYCHOLOGIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DINA LARA SCHOOL PSYCHOLOGIST

II. Dates (important events)

Enumeration Date: 10/18/2024
Last Update Date: 10/18/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HARVEY GREEN ELEMENTARY 42875 GATEWOOD STREET
FREMONT CA
94538
US

IV. Provider business mailing address

4210 TECHNOLOGY DR
FREMONT CA
94538-6337
US

V. Phone/Fax

Practice location:
  • Phone: 510-656-6438
  • Fax:
Mailing address:
  • Phone: 510-657-2350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number240027151
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: