Healthcare Provider Details

I. General information

NPI: 1962487116
Provider Name (Legal Business Name): ERIC L LAVARDA LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 04/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E SAINT JOSEPH ST
GREEN BAY WI
54301-2241
US

IV. Provider business mailing address

301 E SAINT JOSEPH ST
GREEN BAY WI
54301-2241
US

V. Phone/Fax

Practice location:
  • Phone: 920-433-6073
  • Fax:
Mailing address:
  • Phone: 920-433-6073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: