MEDICARE: CHRISTINA LAVIGNE

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	101YP2500X	Professional Counselor	006408	CT
2	101YP2500X	Professional Counselor	PC016244	PA
3	101YP2500X	Professional Counselor	37PC00904800	NJ

General Provider Information

NPI Number	:	1174095491
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINA LAVIGNE

Provider Business Mailing Address
First Line	:	430 NEW PARK AVE STE 102
Second Line	:
City	:	WEST HARTFORD
State	:	CT
Zip	:	06110-1142
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	430 NEW PARK AVE STE 102
Second Line	:
City	:	WEST HARTFORD
State	:	CT
Zip	:	06110-1142
Country	:	US
Telephone Number	:	844-866-8336
Fax Number	:

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

Provider Enumeration Date	:	12/27/2018
Last Update Date	:	12/09/2024

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