Healthcare Provider Details

I. General information

NPI: 1750589479
Provider Name (Legal Business Name): IRENE LARA PSYD, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 11104
SANTA ANA CA
92711-1104
US

IV. Provider business mailing address

PO BOX 11104
SANTA ANA CA
92711-1104
US

V. Phone/Fax

Practice location:
  • Phone: 323-251-6471
  • Fax:
Mailing address:
  • Phone: 760-487-8073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLCS19080
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 19080
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: