Provider Demographics
NPI:1477208411
Name:LAVIOLETTE, MARCEL
Entity Type:Individual
Prefix:
First Name:MARCEL
Middle Name:
Last Name:LAVIOLETTE
Suffix:
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 1:223 6TH ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OR
Mailing Address - Zip Code:97114-9733
Mailing Address - Country:US
Mailing Address - Phone:503-765-4459
Mailing Address - Fax:
Practice Address - Street 1:223 6TH ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OR
Practice Address - Zip Code:97114-9733
Practice Address - Country:US
Practice Address - Phone:503-765-4459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-17
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
ORTHW000106170172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No104100000XBehavioral Health & Social Service ProvidersSocial Worker