Provider Demographics
NPI:1417101114
Name:LAVINE, HAROLD ALLEN JR
Entity Type:Individual
Prefix:MR
First Name:HAROLD
Middle Name:ALLEN
Last Name:LAVINE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1824 MOUNTAINSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-6752
Mailing Address - Country:US
Mailing Address - Phone:757-582-3930
Mailing Address - Fax:
Practice Address - Street 1:917 BEVILLE RD
Practice Address - Street 2:
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-1712
Practice Address - Country:US
Practice Address - Phone:386-756-4395
Practice Address - Fax:866-426-2811
Is Sole Proprietor?:No
Enumeration Date:2008-11-07
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP006634225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist