Healthcare Provider Details

I. General information

NPI: 1164864914
Provider Name (Legal Business Name): GARY WILLIAM LAVIGNA BCBA-D; PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2013
Last Update Date: 07/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5777 W CENTURY BLVD STE 675
LOS ANGELES CA
90045-5632
US

IV. Provider business mailing address

5777 W CENTURY BLVD STE 675
LOS ANGELES CA
90045-5632
US

V. Phone/Fax

Practice location:
  • Phone: 310-871-0702
  • Fax: 818-881-1935
Mailing address:
  • Phone: 310-871-0702
  • Fax: 818-881-1935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY5115
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-02-09-40
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: