Healthcare Provider Details

I. General information

NPI: 1457273617
Provider Name (Legal Business Name): LAVAUGHN BRATHWAITE PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAVAUGHN BRATHWAITE-BORDE PSY.D.

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 W COLUMBIA ST
FARMINGTON MO
63640-2902
US

IV. Provider business mailing address

400 MAPLE VALLEY DR APT 11
FARMINGTON MO
63640-1973
US

V. Phone/Fax

Practice location:
  • Phone: 573-747-2231
  • Fax:
Mailing address:
  • Phone: 636-492-1527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2019035682
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: