Provider Demographics
NPI:1518995117
Name:FORTIN, LAVONNA JUNE (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:LAVONNA
Middle Name:JUNE
Last Name:FORTIN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:LAVONNA
Other - Middle Name:JUNE
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:6103 W AMARILLO BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1936
Mailing Address - Country:US
Mailing Address - Phone:806-355-1559
Mailing Address - Fax:806-355-2273
Practice Address - Street 1:6103 W AMARILLO BLVD STE A
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1936
Practice Address - Country:US
Practice Address - Phone:806-355-1559
Practice Address - Fax:806-355-2273
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31581174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX612312Medicare ID - Type UnspecifiedMEDICARE NUMBER