Provider Demographics
NPI:1770024580
Name:MCINNIS, LAVALLE
Entity Type:Individual
Prefix:
First Name:LAVALLE
Middle Name:
Last Name:MCINNIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14212 LYNDHURST DR
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-8809
Mailing Address - Country:US
Mailing Address - Phone:804-882-3605
Mailing Address - Fax:
Practice Address - Street 1:2663 OSBORNE RD
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23831-2168
Practice Address - Country:US
Practice Address - Phone:804-882-3606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-13
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701007039101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional