Provider Demographics
NPI:1609255819
Name:LAVENDER, LEO W
Entity Type:Individual
Prefix:MR
First Name:LEO
Middle Name:W
Last Name:LAVENDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15912 VINE AVE
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:IL
Mailing Address - Zip Code:60426-5036
Mailing Address - Country:US
Mailing Address - Phone:773-552-4120
Mailing Address - Fax:
Practice Address - Street 1:15912 VINE AVE
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-5036
Practice Address - Country:US
Practice Address - Phone:773-552-4120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-20
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490170791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical