Provider Demographics
NPI:1073916441
Name:LAVINO, STACY (MFC)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:LAVINO
Suffix:
Gender:F
Credentials:MFC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30131 TOWN CENTER DR
Mailing Address - Street 2:SUITE #292
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-2034
Mailing Address - Country:US
Mailing Address - Phone:949-873-4673
Mailing Address - Fax:
Practice Address - Street 1:30131 TOWN CENTER DR
Practice Address - Street 2:SUITE #292
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-2034
Practice Address - Country:US
Practice Address - Phone:949-873-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-30
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC81407106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist