Provider Demographics
NPI:1356839351
Name:LAFAVE, ADAM (TLLP)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:LAFAVE
Suffix:
Gender:M
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1169 JOYCE LN
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-8869
Mailing Address - Country:US
Mailing Address - Phone:616-450-2563
Mailing Address - Fax:
Practice Address - Street 1:3830 PACKARD ST STE 280
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-2276
Practice Address - Country:US
Practice Address - Phone:734-224-2454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301017416103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical