Provider Demographics
NPI:1164864914
Name:LAVIGNA, GARY WILLIAM (BCBA-D; PHD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:WILLIAM
Last Name:LAVIGNA
Suffix:
Gender:M
Credentials:BCBA-D; PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5777 W CENTURY BLVD STE 675
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5632
Mailing Address - Country:US
Mailing Address - Phone:310-871-0702
Mailing Address - Fax:818-881-1935
Practice Address - Street 1:5777 W CENTURY BLVD STE 675
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-5632
Practice Address - Country:US
Practice Address - Phone:310-871-0702
Practice Address - Fax:818-881-1935
Is Sole Proprietor?:No
Enumeration Date:2013-07-22
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-02-09-40103K00000X
CAPSY5115103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-3693249OtherEIN