Provider Demographics
NPI:1518328822
Name:LAVIN, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:LAVIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:256 SE STEPHENS ST
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-3124
Mailing Address - Country:US
Mailing Address - Phone:541-957-5646
Mailing Address - Fax:541-957-0191
Practice Address - Street 1:256 SE STEPHENS ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-3124
Practice Address - Country:US
Practice Address - Phone:541-957-5646
Practice Address - Fax:541-957-0191
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-14
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical