Healthcare Provider Details

I. General information

NPI: 1497072888
Provider Name (Legal Business Name): LARA ALLISON RAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2010
Last Update Date: 11/30/2021
Certification Date: 11/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 UCLA MEDICAL PLZ STE 2200
LOS ANGELES CA
90095-3414
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-9989
  • Fax: 310-393-5659
Mailing address:
  • Phone: 310-301-8707
  • Fax: 310-301-8751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY22240
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberPSY22240
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPSY22240
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY22240
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: