MEDICARE: VICTORIA V LAVIGNE PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC2200X	Clinical Child & Adolescent Psychologist	0712398	IL

General Provider Information

NPI Number	:	1114001690
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICTORIA V LAVIGNE PHD

Provider Business Mailing Address
First Line	:	778 W FRONTAGE RD
Second Line	:	SUITE 123
City	:	NORTHFIELD
State	:	IL
Zip	:	60093-1209
Country	:	US
Telephone Number	:	847-446-7184
Fax Number	:	847-446-7185

Provider Business Practice Location Address
First Line	:	778 W FRONTAGE RD
Second Line	:	SUITE 123
City	:	NORTHFIELD
State	:	IL
Zip	:	60093-1209
Country	:	US
Telephone Number	:	847-446-7184
Fax Number	:	847-446-7185

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/24/2006
Last Update Date	:	07/08/2007

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