Healthcare Provider Details

I. General information

NPI: 1104749860
Provider Name (Legal Business Name): STEPHANIE LYNN LARA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2026
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2051 TEXAS PLAZA DR
IRVING TX
75062-4884
US

IV. Provider business mailing address

2409 W 6TH ST
IRVING TX
75060-3502
US

V. Phone/Fax

Practice location:
  • Phone: 469-321-1721
  • Fax:
Mailing address:
  • Phone: 469-321-1721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number104564
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: