Provider Demographics
NPI:1689103814
Name:ELLISON, LAVINA
Entity Type:Individual
Prefix:
First Name:LAVINA
Middle Name:
Last Name:ELLISON
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 1:16980 NISQUALLI RD APT E103
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-9622
Mailing Address - Country:US
Mailing Address - Phone:760-876-9735
Mailing Address - Fax:
Practice Address - Street 1:10755 APPLE VALLEY RD
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92308
Practice Address - Country:US
Practice Address - Phone:760-247-9840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-10
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA105780106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)