Healthcare Provider Details

I. General information

NPI: 1942022488
Provider Name (Legal Business Name): CHRISTOPHER LARA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 10/28/2024
Certification Date: 10/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7420 HAYWARD RD STE 104
FREDERICK MD
21702-2510
US

IV. Provider business mailing address

PO BOX 3352
GAITHERSBURG MD
20885-3352
US

V. Phone/Fax

Practice location:
  • Phone: 240-575-9480
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: