Provider Demographics
NPI:1780085563
Name:LAVIGNE, ANDREA (PHD)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:LAVIGNE
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 1:24 SALT POND RD
Mailing Address - Street 2:D3
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02879-4314
Mailing Address - Country:US
Mailing Address - Phone:401-789-2306
Mailing Address - Fax:401-789-2307
Practice Address - Street 1:24 SALT POND RD
Practice Address - Street 2:D3
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-4314
Practice Address - Country:US
Practice Address - Phone:401-789-2306
Practice Address - Fax:401-789-2307
Is Sole Proprietor?:No
Enumeration Date:2014-09-11
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS01453103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical