Provider Demographics
NPI:1972066280
Name:LAVACOT, BRIANA
Entity Type:Individual
Prefix:
First Name:BRIANA
Middle Name:
Last Name:LAVACOT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRIANA
Other - Middle Name:
Other - Last Name:ROBERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:235 DUNBAR CAVE RD STE B
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-8829
Mailing Address - Country:US
Mailing Address - Phone:931-444-3583
Mailing Address - Fax:
Practice Address - Street 1:235 DUNBAR CAVE RD STE B
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-8829
Practice Address - Country:US
Practice Address - Phone:931-444-3583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-12
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10477104100000X
TN78631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherN/A