Provider Demographics
NPI:1518078328
Name:LAVINE, ROBERT ALAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ALAN
Last Name:LAVINE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:ROB
Other - Middle Name:ALAN
Other - Last Name:LAVINE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1602 BELLE VIEW BLVD.
Mailing Address - Street 2:# 3374
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22307
Mailing Address - Country:US
Mailing Address - Phone:571-508-8916
Mailing Address - Fax:703-435-7422
Practice Address - Street 1:1602 BELLE VIEW BLVD.
Practice Address - Street 2:# 3374
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22307
Practice Address - Country:US
Practice Address - Phone:571-508-8916
Practice Address - Fax:703-435-7422
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001957103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
127234OtherVALUE OPTIONS
VA100246OtherANTHEM BCBS
VA100246OtherANTHEM BCBS