Provider Demographics
NPI:1083237614
Name:LAVALLEE, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:LAVALLEE
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 1:5 RIPLEY ST
Mailing Address - Street 2:
Mailing Address - City:OAKVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06779-1332
Mailing Address - Country:US
Mailing Address - Phone:203-228-8423
Mailing Address - Fax:
Practice Address - Street 1:130 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-1709
Practice Address - Country:US
Practice Address - Phone:203-228-8423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-18
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT27.002413106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist