Provider Demographics
NPI:1184413601
Name:LARA, JUSTIN FRANCISCO (CADCIII:B00004030425)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:FRANCISCO
Last Name:LARA
Suffix:
Gender:M
Credentials:CADCIII:B00004030425
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 SUNNYSIDE AVE APT 106
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-2940
Mailing Address - Country:US
Mailing Address - Phone:559-975-9240
Mailing Address - Fax:
Practice Address - Street 1:2772 S MARTIN L KING JR BLVD
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93706-5345
Practice Address - Country:US
Practice Address - Phone:559-265-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-01
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB00004030425101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)