MEDICARE: DIANNE LAVIN LLC

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	3587	TX
2	103T00000X	Psychologist	33606	TX

General Provider Information

NPI Number	:	1528598620
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIANNE LAVIN LLC

Provider Business Mailing Address
First Line	:	3955 PALM WAY STE 1
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-3005
Country	:	US
Telephone Number	:	904-685-4850
Fax Number	:	904-685-4850

Provider Business Practice Location Address
First Line	:	503 BENEDICT CT
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-2545
Country	:	US
Telephone Number	:	210-441-1074
Fax Number	:	210-441-1074

Authorized Official
Title or Position	:	PROVIDER/OWNER
Name	:	DIANNE LAVIN
Credential	:	PSYD, RN
Telephone Number	:	210-441-1074

Provider Enumeration Date	:	06/13/2017
Last Update Date	:	08/17/2017

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