MEDICARE: LARA MAE NISPEROS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106E00000X	Assistant Behavior Analyst		CA

General Provider Information

NPI Number	:	1194293514
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARA MAE NISPEROS

Provider Business Mailing Address
First Line	:	1478 STONE POINT DR STE 200
Second Line	:
City	:	ROSEVILLE
State	:	CA
Zip	:	95661-2869
Country	:	US
Telephone Number	:	408-204-5502
Fax Number	:

Provider Business Practice Location Address
First Line	:	1478 STONE POINT DR STE 200
Second Line	:
City	:	ROSEVILLE
State	:	CA
Zip	:	95661-2869
Country	:	US
Telephone Number	:	408-204-5502
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/02/2018
Last Update Date	:	02/17/2026

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Directions to “ LARA MAE NISPEROS ” Practice Location

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