Provider Demographics
NPI:1699215897
Name:LAVINIO, BAILY BRENNAN
Entity Type:Individual
Prefix:
First Name:BAILY
Middle Name:BRENNAN
Last Name:LAVINIO
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 1:12415 NAUTILUS CIR
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33412-2488
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2415 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-4009
Practice Address - Country:US
Practice Address - Phone:310-526-4494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-07
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP03920101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health