Provider Demographics
NPI:1932467321
Name:BRYAN, LAVONNE
Entity Type:Individual
Prefix:
First Name:LAVONNE
Middle Name:
Last Name:BRYAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:LAVONNE
Other - Middle Name:NICOLE
Other - Last Name:BASKERVILLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 34703
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1703
Mailing Address - Country:US
Mailing Address - Phone:206-764-3335
Mailing Address - Fax:206-764-0489
Practice Address - Street 1:10001 17TH PL S
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98168-1615
Practice Address - Country:US
Practice Address - Phone:206-766-6976
Practice Address - Fax:206-766-6993
Is Sole Proprietor?:No
Enumeration Date:2012-04-24
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC602478888101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor