Healthcare Provider Details

I. General information

NPI: 1922314640
Provider Name (Legal Business Name): INGA LAVROVA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2010
Last Update Date: 02/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12510 VAN NUYS BLVD
PACOIMA CA
91331-1338
US

IV. Provider business mailing address

12510 VAN NUYS BLVD
PACOIMA CA
91331-1338
US

V. Phone/Fax

Practice location:
  • Phone: 818-896-2255
  • Fax:
Mailing address:
  • Phone: 818-896-2255
  • Fax: 818-897-1766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number68263
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: