Provider Demographics
NPI:1497951198
Name:WAYNE LAVENDER PHD
Entity Type:Organization
Organization Name:WAYNE LAVENDER PHD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:J
Authorized Official - Last Name:LAVENDER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:718-596-7442
Mailing Address - Street 1:62 PIERREPONT ST
Mailing Address - Street 2:# 1E
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-2452
Mailing Address - Country:US
Mailing Address - Phone:718-596-7442
Mailing Address - Fax:
Practice Address - Street 1:62 PIERREPONT ST
Practice Address - Street 2:# 1E
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-2452
Practice Address - Country:US
Practice Address - Phone:718-596-7442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4755103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty