Healthcare Provider Details

I. General information

NPI: 1053765669
Provider Name (Legal Business Name): TARA CHRISTINE LAVAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2016
Last Update Date: 03/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 SW ARCHER RD NF/SG MALCALM RANDALL VA MEDICAL CENTER
GAINESVILLE FL
32608-1197
US

IV. Provider business mailing address

1601 SW ARCHER RD
GAINESVILLE FL
32608-1197
US

V. Phone/Fax

Practice location:
  • Phone: 352-548-6000
  • Fax:
Mailing address:
  • Phone: 352-548-1800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW 11865
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: