Healthcare Provider Details

I. General information

NPI: 1447482641
Provider Name (Legal Business Name): CHARLES HENRY LAVINE LPC-S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2009
Last Update Date: 08/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 BURCHILL RD N
FORT WORTH TX
76105-3012
US

IV. Provider business mailing address

2701 BURCHILL RD N
FORT WORTH TX
76105-3012
US

V. Phone/Fax

Practice location:
  • Phone: 817-534-0814
  • Fax: 817-536-1556
Mailing address:
  • Phone: 817-534-0814
  • Fax: 817-536-1556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number13146
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: