Provider Demographics
NPI:1316391394
Name:LAVRADOR, DEIDRE (LMFT)
Entity Type:Individual
Prefix:
First Name:DEIDRE
Middle Name:
Last Name:LAVRADOR
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 SUNRISE AVE STE 115D
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-4509
Mailing Address - Country:US
Mailing Address - Phone:916-850-0147
Mailing Address - Fax:916-772-8527
Practice Address - Street 1:720 SUNRISE AVE STE 115D
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4509
Practice Address - Country:US
Practice Address - Phone:916-850-0147
Practice Address - Fax:916-772-8527
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-15
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA90272106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist