Provider Demographics
NPI:1558498089
Name:LAVIGNA, GRANT (LMFT)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:LAVIGNA
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 GRANADA ST
Mailing Address - Street 2:SUITE N
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-7866
Mailing Address - Country:US
Mailing Address - Phone:805-987-3162
Mailing Address - Fax:805-383-1502
Practice Address - Street 1:155 GRANADA ST
Practice Address - Street 2:SUITE N
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-7866
Practice Address - Country:US
Practice Address - Phone:805-987-3162
Practice Address - Fax:805-383-1502
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 46649106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist