MEDICARE: TERESA LARA

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	224Z00000X	Occupational Therapy Assistant	3599	NM

General Provider Information

NPI Number	:	1962951194
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERESA LARA

Provider Business Mailing Address
First Line	:	7 HENDRIX LN
Second Line	:
City	:	LOS LUNAS
State	:	NM
Zip	:	87031-6917
Country	:	US
Telephone Number	:	505-967-1834
Fax Number	:

Provider Business Practice Location Address
First Line	:	7 HENDRIX LN
Second Line	:
City	:	LOS LUNAS
State	:	NM
Zip	:	87031-6917
Country	:	US
Telephone Number	:	505-967-1834
Fax Number	:

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

Provider Enumeration Date	:	09/29/2016
Last Update Date	:	09/29/2016

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Directions to “ TERESA LARA ” Practice Location

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