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NPI Code Detail

MEDICARE: CHARLES HENRY LAVINE LPC-S

MEDICARE: CHARLES HENRY LAVINE LPC-S
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
1101YM0800XMental Health Counselor13146TX

General Provider Information

NPI Number : 1447482641
Entity Type Code : Individual
Provider Name (Legal Business Name) : CHARLES HENRY LAVINE LPC-S
Provider Business Mailing Address
First Line : 2701 BURCHILL RD N
Second Line :
City : FORT WORTH
State : TX
Zip : 76105-3012
Country : US
Telephone Number : 817-534-0814
Fax Number : 817-536-1556
Provider Business Practice Location Address
First Line : 2701 BURCHILL RD N
Second Line :
City : FORT WORTH
State : TX
Zip : 76105-3012
Country : US
Telephone Number : 817-534-0814
Fax Number : 817-536-1556
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/20/2009
Last Update Date : 08/20/2009

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