Provider Demographics
NPI:1184131518
Name:LAVERNE, CHARLOTTE B (MED, LAT, ATC)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:B
Last Name:LAVERNE
Suffix:
Gender:F
Credentials:MED, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 TODD CT
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77386-1245
Mailing Address - Country:US
Mailing Address - Phone:832-316-3896
Mailing Address - Fax:
Practice Address - Street 1:6101 RESEARCH FOREST DR
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77381-6028
Practice Address - Country:US
Practice Address - Phone:936-709-1068
Practice Address - Fax:936-709-1068
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX09122255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer