Provider Demographics
NPI:1144558610
Name:LARI, MANZAR IMTIAZ (MA, LP, LICSW)
Entity type:Individual
Prefix:MR
First Name:MANZAR
Middle Name:IMTIAZ
Last Name:LARI
Suffix:
Gender:M
Credentials:MA, LP, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 MAINSTREET
Mailing Address - Street 2:#314
Mailing Address - City:HOPKINS
Mailing Address - State:MN
Mailing Address - Zip Code:55343-7700
Mailing Address - Country:US
Mailing Address - Phone:612-327-6786
Mailing Address - Fax:
Practice Address - Street 1:2908 HUMBOLDT AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-1953
Practice Address - Country:US
Practice Address - Phone:612-327-6786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-21
Last Update Date:2009-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1335103T00000X
MN064211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical