Provider Demographics
NPI:1083741102
Name:LAVINE-ANDERSON, NANCY C (OTR,L)
Entity Type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:C
Last Name:LAVINE-ANDERSON
Suffix:
Gender:F
Credentials:OTR,L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5320 WELLESLEY ST
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-4446
Mailing Address - Country:US
Mailing Address - Phone:619-528-4081
Mailing Address - Fax:619-528-4026
Practice Address - Street 1:6160 MISSION GORGE RD
Practice Address - Street 2:SUITE# 305
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-3410
Practice Address - Country:US
Practice Address - Phone:619-528-4081
Practice Address - Fax:619-528-4026
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0T3155251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOT3155OtherOT LICENSE