Provider Demographics
NPI:1073736831
Name:LAVINE, JANICE M (PHD)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:M
Last Name:LAVINE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JAN
Other - Middle Name:M
Other - Last Name:LAVINE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5001 AMERICAN BLVD W
Mailing Address - Street 2:990
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55437-1108
Mailing Address - Country:US
Mailing Address - Phone:952-897-0506
Mailing Address - Fax:
Practice Address - Street 1:5001 AMERICAN BLVD W
Practice Address - Street 2:990
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55437-1108
Practice Address - Country:US
Practice Address - Phone:952-897-0506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6676104100000X
MN266106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist