Provider Demographics
NPI:1225500952
Name:LARA, REBECCA (MSW)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:LARA
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 W ACRES RD
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-5855
Mailing Address - Country:US
Mailing Address - Phone:815-272-7310
Mailing Address - Fax:
Practice Address - Street 1:304 W MONDAMIN ST STE 104
Practice Address - Street 2:
Practice Address - City:MINOOKA
Practice Address - State:IL
Practice Address - Zip Code:60447-4618
Practice Address - Country:US
Practice Address - Phone:815-272-7310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-19
Last Update Date:2024-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041S0200X
IL149.0261291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL66416492Medicaid