Provider Demographics
NPI:1295476158
Name:MARKS, LAVERNE DIANE (PHD)
Entity type:Individual
Prefix:DR
First Name:LAVERNE
Middle Name:DIANE
Last Name:MARKS
Suffix:
Gender:F
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:PO BOX 7187
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-0187
Mailing Address - Country:US
Mailing Address - Phone:856-278-3349
Mailing Address - Fax:
Practice Address - Street 1:145 COUNTY ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-3301
Practice Address - Country:US
Practice Address - Phone:856-278-3349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006574101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT006574OtherDEPARTMENT OF PUBLIC HEALTH