Provider Demographics
NPI:1588682652
Name:PATTERSON, LAVONNA D (PHD)
Entity Type:Individual
Prefix:DR
First Name:LAVONNA
Middle Name:D
Last Name:PATTERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:LAVONNA
Other - Middle Name:BROWN
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:111 E 16TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-5919
Mailing Address - Country:US
Mailing Address - Phone:208-523-1130
Mailing Address - Fax:208-529-6501
Practice Address - Street 1:111 E 16TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-5919
Practice Address - Country:US
Practice Address - Phone:208-523-1130
Practice Address - Fax:208-529-6501
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY202117103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002648300Medicaid
IDN6168OtherBLUE CROSS
ID820428306OtherTRICARE