Provider Demographics
NPI:1770966756
Name:LAVIN, AMANDA ANNE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:ANNE
Last Name:LAVIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 7TH ST
Mailing Address - Street 2:
Mailing Address - City:VANDLING
Mailing Address - State:PA
Mailing Address - Zip Code:18421-1738
Mailing Address - Country:US
Mailing Address - Phone:570-285-7709
Mailing Address - Fax:
Practice Address - Street 1:303 7TH ST
Practice Address - Street 2:
Practice Address - City:VANDLING
Practice Address - State:PA
Practice Address - Zip Code:18421-1738
Practice Address - Country:US
Practice Address - Phone:570-285-7709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA101YS0200X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst