Provider Demographics
NPI:1861836223
Name:LAVENDER, NEIL JACK (PHD)
Entity Type:Individual
Prefix:DR
First Name:NEIL
Middle Name:JACK
Last Name:LAVENDER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1026 SEAMAN AVE
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08722-3406
Mailing Address - Country:US
Mailing Address - Phone:732-674-0830
Mailing Address - Fax:
Practice Address - Street 1:1026 SEAMAN AVE
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08722-3406
Practice Address - Country:US
Practice Address - Phone:732-674-0830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-28
Last Update Date:2013-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNJ2976101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health