Healthcare Provider Details

I. General information

NPI: 1356741490
Provider Name (Legal Business Name): LAVONNA CONNELL PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2014
Last Update Date: 04/19/2026
Certification Date: 04/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 475 BOX 1
FPO AP
96350-1200
US

IV. Provider business mailing address

PSC 475 BOX 1
FPO AP
96350-1200
US

V. Phone/Fax

Practice location:
  • Phone: --
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number37752
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: