Provider Demographics
NPI:1780392688
Name:LARA, ROXANNE (LCSW)
Entity type:Individual
Prefix:
First Name:ROXANNE
Middle Name:
Last Name:LARA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3475 W SHAW AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-3200
Mailing Address - Country:US
Mailing Address - Phone:559-271-1186
Mailing Address - Fax:559-271-8041
Practice Address - Street 1:3475 W SHAW AVE STE 101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3200
Practice Address - Country:US
Practice Address - Phone:559-271-1186
Practice Address - Fax:559-271-8041
Is Sole Proprietor?:No
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW1076551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical