MEDICARE: NATALIE JOAN LARES D.O.

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	2084P0800X	Psychiatry Physician	5101025693	MI

General Provider Information

NPI Number	:	1255786612
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NATALIE JOAN LARES D.O.

Provider Business Mailing Address
First Line	:	41000 WOODWARD AVE STE 350
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48304-5092
Country	:	US
Telephone Number	:	248-325-8857
Fax Number	:

Provider Business Practice Location Address
First Line	:	19000 ST JOES PKWY STE 310
Second Line	:
City	:	LIVONIA
State	:	MI
Zip	:	48152-1477
Country	:	US
Telephone Number	:	734-743-4540
Fax Number	:

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

Provider Enumeration Date	:	05/04/2016
Last Update Date	:	03/10/2025

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