Provider Demographics
NPI:1245246073
Name:LAVIN, MARY ELLEN (PH D)
Entity Type:Individual
Prefix:DR
First Name:MARY ELLEN
Middle Name:
Last Name:LAVIN
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 3RD ST
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-1962
Mailing Address - Country:US
Mailing Address - Phone:847-251-3441
Mailing Address - Fax:
Practice Address - Street 1:400 LINDEN AVE
Practice Address - Street 2:
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-3606
Practice Address - Country:US
Practice Address - Phone:847-256-6440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional