Healthcare Provider Details

I. General information

NPI: 1780392688
Provider Name (Legal Business Name): ROXANNE LARA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2022
Last Update Date: 11/09/2022
Certification Date: 11/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3475 W SHAW AVE STE 101
FRESNO CA
93711-3200
US

IV. Provider business mailing address

3475 W SHAW AVE STE 101
FRESNO CA
93711-3200
US

V. Phone/Fax

Practice location:
  • Phone: 559-271-1186
  • Fax: 559-271-8041
Mailing address:
  • Phone: 559-271-1186
  • Fax: 559-271-8041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW107655
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: