Provider Demographics
NPI:1851702021
Name:LAVALLEE, LORRAINE
Entity Type:Individual
Prefix:MRS
First Name:LORRAINE
Middle Name:
Last Name:LAVALLEE
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:LORRAINE
Other - Middle Name:
Other - Last Name:VICELJA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:599 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-3105
Mailing Address - Country:US
Mailing Address - Phone:310-831-0331
Mailing Address - Fax:
Practice Address - Street 1:599 W 9TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-3105
Practice Address - Country:US
Practice Address - Phone:310-831-0331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-09
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF74546106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist