Provider Demographics
NPI:1275793853
Name:WILLSON, LAVERNE CLARENCE (LICENSED HEARING INS)
Entity Type:Individual
Prefix:MR
First Name:LAVERNE
Middle Name:CLARENCE
Last Name:WILLSON
Suffix:
Gender:M
Credentials:LICENSED HEARING INS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 W MAIN
Mailing Address - Street 2:SUITE 106 HEAR BETTER HERE HEARING CENTER
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-2438
Mailing Address - Country:US
Mailing Address - Phone:605-355-9776
Mailing Address - Fax:
Practice Address - Street 1:2525 WEST MAIN
Practice Address - Street 2:SUITE 106
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-2438
Practice Address - Country:US
Practice Address - Phone:605-355-9776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD257237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9159920Medicaid