Provider Demographics
NPI:1134310956
Name:LAVALLEE CORPORATION
Entity Type:Organization
Organization Name:LAVALLEE CORPORATION
Other - Org Name:PHASES OF CHANGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:LAVALLEE
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:801-695-0386
Mailing Address - Street 1:121 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-2704
Mailing Address - Country:US
Mailing Address - Phone:801-695-0386
Mailing Address - Fax:
Practice Address - Street 1:121 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-2704
Practice Address - Country:US
Practice Address - Phone:801-695-0386
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3314093902320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT788007788057Medicaid