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General NPI Number Information
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NPI Number | 1306118468
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Entity Type | Individual
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Provider Name | MARIO LARA BA
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Gender | Male
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Dates
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Enumeration Date | 02/06/2012
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Last Update Date | 02/06/2012
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Provider Practice Location Address
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Address Line | 3176 LANCER ST
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City | PORTAGE
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State | IN
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Zip | 46368-4408
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Country | US
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Telephone | 219-763-8823
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Fax |
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Provider Business Mailing Address
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Address Line | 579 W 450 S
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City | HEBRON
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State | IN
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Zip | 46341-8819
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Country | US
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Telephone | 219-763-8823
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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