Healthcare Provider Details

I. General information

NPI: 1861366619
Provider Name (Legal Business Name): PAUL ANTHONY LAVAN III RSS,COACH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2025
Last Update Date: 10/03/2025
Certification Date: 10/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

846 WETHERSFIELD AVE STE 101
HARTFORD CT
06114-3180
US

IV. Provider business mailing address

627 BROAD ST APT D
HARTFORD CT
06106-4630
US

V. Phone/Fax

Practice location:
  • Phone: 860-962-1803
  • Fax:
Mailing address:
  • Phone: 860-962-1803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: