Individual
MAYRA LARA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
1200 S ELMIRA AVE, RUSSELLVILLE, AR 72802-9646
(479) 968-7118
(479) 968-8628
Mailing address
PO DRAWER 2109, RUSSELLVILLE, AR 72811
(479) 967-2322
(479) 967-2876
Taxonomy
Speciality
Code
Description
License number
State
106S00000X
Behavior Technician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
273474706
—
AR
Enumeration date
08/10/2021
Last updated
01/13/2023
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