Provider Demographics
NPI:1043631310
Name:LAVACHE, CHIPPY
Entity Type:Individual
Prefix:
First Name:CHIPPY
Middle Name:
Last Name:LAVACHE
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 1:630 S GARNETT ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27536-4509
Mailing Address - Country:US
Mailing Address - Phone:919-226-3180
Mailing Address - Fax:919-226-3183
Practice Address - Street 1:630 S GARNETT ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-4509
Practice Address - Country:US
Practice Address - Phone:919-226-3180
Practice Address - Fax:919-226-3183
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-03
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-032-525251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health