Provider Demographics
NPI:1528598620
Name:DIANNE LAVIN LLC
Entity Type:Organization
Organization Name:DIANNE LAVIN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, RN
Authorized Official - Phone:210-441-1074
Mailing Address - Street 1:3955 PALM WAY STE 1
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-3005
Mailing Address - Country:US
Mailing Address - Phone:904-685-4850
Mailing Address - Fax:904-685-4850
Practice Address - Street 1:503 BENEDICT CT
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-2545
Practice Address - Country:US
Practice Address - Phone:210-441-1074
Practice Address - Fax:210-441-1074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-13
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33606103T00000X
TX3587363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty