Provider Demographics
NPI:1861366619
Name:LAVAN, PAUL ANTHONY III (RSS,COACH)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:ANTHONY
Last Name:LAVAN
Suffix:III
Gender:M
Credentials:RSS,COACH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:627 BROAD ST APT D
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-4630
Mailing Address - Country:US
Mailing Address - Phone:860-962-1803
Mailing Address - Fax:
Practice Address - Street 1:846 WETHERSFIELD AVE STE 101
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06114-3180
Practice Address - Country:US
Practice Address - Phone:860-962-1803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-03
Last Update Date:2025-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT101Y00000X, 106S00000X, 251B00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No251B00000XAgenciesCase Management