Provider Demographics
NPI:1083970289
Name:LAVENDER, PHILLIP M (BHRS)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:M
Last Name:LAVENDER
Suffix:
Gender:M
Credentials:BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 W WILLOW RD
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-2437
Mailing Address - Country:US
Mailing Address - Phone:580-484-1018
Mailing Address - Fax:
Practice Address - Street 1:1600 W WILLOW RD
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-2437
Practice Address - Country:US
Practice Address - Phone:580-484-1018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-02
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health