Healthcare Provider Details

I. General information

NPI: 1023739794
Provider Name (Legal Business Name): CHRISTINE MARIE DE LARA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2022
Last Update Date: 01/19/2023
Certification Date: 01/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 GRAND AVE STE D
SACRAMENTO CA
95838-3466
US

IV. Provider business mailing address

9117 NEWHALL DR APT 15
SACRAMENTO CA
95826-5373
US

V. Phone/Fax

Practice location:
  • Phone: 916-561-6090
  • Fax:
Mailing address:
  • Phone: 619-771-7726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number137186
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: