Provider Demographics
NPI:1891174181
Name:LAVENDER AVENUE THERAPEUTICS, PC
Entity Type:Organization
Organization Name:LAVENDER AVENUE THERAPEUTICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASMINE
Authorized Official - Middle Name:T
Authorized Official - Last Name:IRVIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:919-302-2308
Mailing Address - Street 1:210 W LAVENDER AVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-4251
Mailing Address - Country:US
Mailing Address - Phone:919-302-2308
Mailing Address - Fax:
Practice Address - Street 1:210 W LAVENDER AVE
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-4251
Practice Address - Country:US
Practice Address - Phone:919-302-2308
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-20
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4548103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty