Provider Demographics
NPI:1629534383
Name:LAVELLE, RENEE SUSAN
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:SUSAN
Last Name:LAVELLE
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 1:1750 SHERRY LN APT 19
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-7646
Mailing Address - Country:US
Mailing Address - Phone:949-870-2256
Mailing Address - Fax:
Practice Address - Street 1:1750 SHERRY LN APT 19
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-7646
Practice Address - Country:US
Practice Address - Phone:949-870-2256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-18
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician