Provider Demographics
NPI:1538704887
Name:LAVESPERE, LAURA KAY
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:KAY
Last Name:LAVESPERE
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 1:345 BEVILLE RD STE 106
Mailing Address - Street 2:
Mailing Address - City:SOUTH DAYTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32119-2147
Mailing Address - Country:US
Mailing Address - Phone:386-760-7533
Mailing Address - Fax:386-761-5868
Practice Address - Street 1:345 BEVILLE RD STE 106
Practice Address - Street 2:
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-2147
Practice Address - Country:US
Practice Address - Phone:386-760-7533
Practice Address - Fax:386-761-5868
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-11
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1609083476Medicaid