Provider Demographics
NPI:1588817639
Name:LAVINE, MINDY HARTMAN (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MINDY
Middle Name:HARTMAN
Last Name:LAVINE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-2634
Mailing Address - Country:US
Mailing Address - Phone:518-232-6395
Mailing Address - Fax:
Practice Address - Street 1:551 BAY RD
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-1441
Practice Address - Country:US
Practice Address - Phone:518-798-4056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-02
Last Update Date:2008-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013594-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist