Healthcare Provider Details

I. General information

NPI: 1770899650
Provider Name (Legal Business Name): MELISSA ANN LARA LMHC, BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2010
Last Update Date: 04/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 MCINTOSH AVE
ORANGE PARK FL
32073-4834
US

IV. Provider business mailing address

1142 GARRISON DR
ST AUGUSTINE FL
32092-1019
US

V. Phone/Fax

Practice location:
  • Phone: 904-596-9986
  • Fax: 904-596-9988
Mailing address:
  • Phone: 904-596-9986
  • Fax: 904-596-9988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH12293
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: