=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578753950
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELISA LARA CADC-CAS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2007
-----------------------------------------------------
Last Update Date | 06/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 40 W G ST STE C
-----------------------------------------------------
City | LOS BANOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93635-3657
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-710-6100
-----------------------------------------------------
Fax | 209-827-2009
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2087
-----------------------------------------------------
City | MERCED
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95344-0087
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-381-6800
-----------------------------------------------------
Fax | 209-385-3174
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | C13861214
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------