Provider Demographics
NPI:1376528174
Name:LAVELLE, PATRICIA CRANNY
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:CRANNY
Last Name:LAVELLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 W BROWN PL
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105
Mailing Address - Country:US
Mailing Address - Phone:605-336-1974
Mailing Address - Fax:605-336-9031
Practice Address - Street 1:5024 S BUR OAK PL STE 212
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-2238
Practice Address - Country:US
Practice Address - Phone:605-275-2001
Practice Address - Fax:605-275-2019
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDLMFT1063101YM0800X
SDLPCMH 2066101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
4998513OtherBLUE CROSS BLUE SHIELD
SD6575452Medicaid