Provider Demographics
NPI:1639315021
Name:LAVAIL, CHRISTINA RENEE
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:RENEE
Last Name:LAVAIL
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:PO BOX 45681
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87174-5681
Mailing Address - Country:US
Mailing Address - Phone:505-226-1960
Mailing Address - Fax:505-672-7769
Practice Address - Street 1:4801 LANG AVE NE
Practice Address - Street 2:UNIT 110
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4475
Practice Address - Country:US
Practice Address - Phone:505-705-1701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-06
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0131051101YM0800X
NMT-0122831101YM0800X
NMCMF0140161106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health