Provider Demographics
NPI:1376754697
Name:LAVELLE, TRACI JEANINE
Entity Type:Individual
Prefix:MISS
First Name:TRACI
Middle Name:JEANINE
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 1:8415 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90047-3044
Mailing Address - Country:US
Mailing Address - Phone:323-759-2569
Mailing Address - Fax:323-759-9429
Practice Address - Street 1:8415 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90047-3044
Practice Address - Country:US
Practice Address - Phone:323-759-2569
Practice Address - Fax:323-759-9429
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator