Provider Demographics
NPI:1679865539
Name:LAVIN, MELISSA (PSYD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:LAVIN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:DIDOMENICO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:3333 CLARK RD STE 110
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34231-8437
Mailing Address - Country:US
Mailing Address - Phone:858-859-0822
Mailing Address - Fax:941-924-7546
Practice Address - Street 1:3333 CLARK RD STE 110
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34231-8437
Practice Address - Country:US
Practice Address - Phone:858-859-0822
Practice Address - Fax:941-924-7546
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-11
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TA0700X, 103TB0200X, 103TC1900X, 103TC2200X, 103T00000X, 103TF0000X, 103TF0000X
NH1359103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3104605Medicaid
FLPY10924OtherFL DEPARTMENT OF HEALTH DIVISION OF MEDICAL QUALITY ASSURANCE
NH1359OtherSTATE OF NH BOARD OF PSYCHOLOGIST