Provider Demographics
NPI:1114001690
Name:LAVIGNE, VICTORIA V (PHD)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:V
Last Name:LAVIGNE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:778 W FRONTAGE RD
Mailing Address - Street 2:SUITE 123
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-1209
Mailing Address - Country:US
Mailing Address - Phone:847-446-7184
Mailing Address - Fax:847-446-7185
Practice Address - Street 1:778 W FRONTAGE RD
Practice Address - Street 2:SUITE 123
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-1209
Practice Address - Country:US
Practice Address - Phone:847-446-7184
Practice Address - Fax:847-446-7185
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0712398103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent