Provider Demographics
NPI:1164567285
Name:HAVERT, LAWRENCE JOHN (PHD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:JOHN
Last Name:HAVERT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 E FOOTHILL BLVD
Mailing Address - Street 2:ROOM E134
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-5230
Mailing Address - Country:US
Mailing Address - Phone:909-421-9440
Mailing Address - Fax:909-873-4466
Practice Address - Street 1:850 E FOOTHILL BLVD
Practice Address - Street 2:ROOM E134
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-5230
Practice Address - Country:US
Practice Address - Phone:909-421-9440
Practice Address - Fax:909-873-4466
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14327103T00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL14327OMedicare ID - Type Unspecified
CAP46481Medicare UPIN