Individual
AUDREY LARA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
3 PINE PL, ROSWELL, NM 88203-1642
(575) 627-3996
Mailing address
3 PINE PL, ROSWELL, NM 88203-1642
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
X-06762
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
X-06762
PROVISIONAL MASTERS SOCIAL WORKER
NM
Enumeration date
06/01/2010
Last updated
06/01/2010
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