Provider Demographics
NPI:1245605567
Name:LAVINE, ROGER
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:LAVINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:SHILLINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:19607-2508
Mailing Address - Country:US
Mailing Address - Phone:610-413-5875
Mailing Address - Fax:
Practice Address - Street 1:697 READING AVE
Practice Address - Street 2:
Practice Address - City:WEST READING
Practice Address - State:PA
Practice Address - Zip Code:19611-1009
Practice Address - Country:US
Practice Address - Phone:610-413-5875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-11
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC006558101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional