Provider Demographics
NPI:1386854388
Name:DELAVERGNE, REAL (LCDC)
Entity Type:Individual
Prefix:MR
First Name:REAL
Middle Name:
Last Name:DELAVERGNE
Suffix:
Gender:M
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3304 CEDARCREST DR
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77503-2122
Mailing Address - Country:US
Mailing Address - Phone:281-212-2918
Mailing Address - Fax:
Practice Address - Street 1:1300 BAY AREA BLVD # A
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77058-2505
Practice Address - Country:US
Practice Address - Phone:281-212-2918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9214101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)