Provider Demographics
NPI:1023021987
Name:LAVALLEE, AFTON (PHD)
Entity Type:Individual
Prefix:
First Name:AFTON
Middle Name:
Last Name:LAVALLEE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8615 ANCHOR ON LANIER CT
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30506-6785
Mailing Address - Country:US
Mailing Address - Phone:770-534-9100
Mailing Address - Fax:770-534-9104
Practice Address - Street 1:8615 ANCHOR ON LANIER CT
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30506-6785
Practice Address - Country:US
Practice Address - Phone:770-534-9100
Practice Address - Fax:770-534-9104
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY001728103TC0700X, 103TC0700X
103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000546334AMedicaid
GA332060OtherPHCS IND. PROVIDER NUM
GAPV138448OtherAPS HC IND. PROVIDER NUM
GAIP118074OtherMAGELLAN IND. NUM
GA68BBFJZMedicare ID - Type UnspecifiedMCR PROVIDER NUM
GA332060OtherPHCS IND. PROVIDER NUM