Provider Demographics
NPI:1225705924
Name:LAVINE, SIMONE ALLEGRA (LAC)
Entity Type:Individual
Prefix:
First Name:SIMONE
Middle Name:ALLEGRA
Last Name:LAVINE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 W 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:RUNNEMEDE
Mailing Address - State:NJ
Mailing Address - Zip Code:08078-1316
Mailing Address - Country:US
Mailing Address - Phone:408-691-6669
Mailing Address - Fax:
Practice Address - Street 1:19 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-2172
Practice Address - Country:US
Practice Address - Phone:856-985-9091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00596300101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health