Provider Demographics
NPI:1982282323
Name:LAVERY, CARRIE-ANN
Entity Type:Individual
Prefix:
First Name:CARRIE-ANN
Middle Name:
Last Name:LAVERY
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 1:2013 NE 178TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-0772
Mailing Address - Country:US
Mailing Address - Phone:360-969-2125
Mailing Address - Fax:
Practice Address - Street 1:16915 SE NAEGELI DR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-1369
Practice Address - Country:US
Practice Address - Phone:360-969-2125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-29
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACB61120747106S00000X
ORABA-IN-10206589106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician