Provider Demographics
NPI:1336784875
Name:LAVINE, ROGER J JR (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:J
Last Name:LAVINE
Suffix:JR
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2808 NE 33RD CT APT 203
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33306-3014
Mailing Address - Country:US
Mailing Address - Phone:954-716-6702
Mailing Address - Fax:
Practice Address - Street 1:222 COMMERCIAL BLVD STE 200
Practice Address - Street 2:
Practice Address - City:LAUDERDALE BY THE SEA
Practice Address - State:FL
Practice Address - Zip Code:33308-4483
Practice Address - Country:US
Practice Address - Phone:954-716-6702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-07
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY10647103TE1100X, 103TF0000X, 103TP2701X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & Sports
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy