Provider Demographics
NPI:1760217830
Name:CONWAY, LARA
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:
Last Name:CONWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3109 W DR MARTIN LUTHER KING JR BLVD STE AND501
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6260
Mailing Address - Country:US
Mailing Address - Phone:813-289-0760
Mailing Address - Fax:
Practice Address - Street 1:3109 W DR MARTIN LUTHER KING JR BLVD STE AND501
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6260
Practice Address - Country:US
Practice Address - Phone:813-289-0760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-06
Last Update Date:2024-09-30
Deactivation Date:2024-09-09
Deactivation Code:
Reactivation Date:2024-09-30
Provider Licenses
StateLicense IDTaxonomies
MDRBT-24-364416106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst