Healthcare Provider Details

I. General information

NPI: 1316772809
Provider Name (Legal Business Name): LAVENNA TAYLOR CDCA, CPRS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2024
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

282 STELTON RD
XENIA OH
45385-5220
US

IV. Provider business mailing address

PO BOX 212
XENIA OH
45385-0212
US

V. Phone/Fax

Practice location:
  • Phone: 937-708-8348
  • Fax:
Mailing address:
  • Phone: 937-708-8348
  • Fax: 937-660-5656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.188237
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberAPS.004331
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: