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General NPI Number Information
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NPI Number | 1225561103
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Entity Type | Organization
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Legal Business Name | LARA T. SAN PEDRO, PSY.D., A PSYCHOLOGICAL CORPORATION
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Dates
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Enumeration Date | 04/06/2017
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Last Update Date | 04/06/2017
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Provider Practice Location Address
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Address Line | 39210 STATE ST SUITE 200
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City | FREMONT
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State | CA
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Zip | 94538-1456
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Country | US
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Telephone | 209-373-0884
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Fax |
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Provider Business Mailing Address
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Address Line | 39210 STATE ST SUITE 200
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City | FREMONT
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State | CA
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Zip | 94538-1456
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Country | US
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Telephone | 209-373-0884
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Fax |
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | LARA SAN PEDRO
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Credential | PSYD
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Telephone | 209-373-0884
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 28229
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License Number State | CA
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