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General NPI Number Information
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NPI Number | 1093443715
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Entity Type | Individual
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Provider Name | LARA GABRIELLE ELY
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Gender | Female
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Dates
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Enumeration Date | 08/10/2022
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Last Update Date | 07/26/2023
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Provider Practice Location Address
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Address Line | 2400 N CARROLL AVE
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City | SOUTHLAKE
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State | TX
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Zip | 76092-3105
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Country | US
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Telephone | 817-949-8400
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Fax |
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Provider Business Mailing Address
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Address Line | 4114 COZY PINE DR
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City | NORTHLAKE
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State | TX
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Zip | 76226-2722
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Country | US
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Telephone | 817-657-2106
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 116742
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License Number State | TX
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