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General NPI Number Information
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NPI Number | 1336784875
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Entity Type | Individual
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Provider Name | ROGER J LAVINE JR. PSYD.
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Gender | Male
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Dates
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Enumeration Date | 11/07/2019
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Last Update Date | 11/07/2019
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Provider Practice Location Address
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Address Line | 222 COMMERCIAL BLVD STE 200
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City | LAUDERDALE BY THE SEA
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State | FL
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Zip | 33308-4483
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Country | US
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Telephone | 954-716-6702
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Fax |
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Provider Business Mailing Address
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Address Line | 2808 NE 33RD CT APT 203
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City | FORT LAUDERDALE
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State | FL
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Zip | 33306-3014
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Country | US
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Telephone | 954-716-6702
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TE1100X
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Taxonomy Name | Exercise & Sports Psychologist
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License Number | PY10647
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 103TF0000X
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Taxonomy Name | Family Psychologist
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License Number | PY10647
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 103TP2701X
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Taxonomy Name | Group Psychotherapy Psychologist
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License Number | PY10647
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License Number State | FL
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Taxonomy #4
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PY10647
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License Number State | FL
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