Basic Information
| Provider Information | |||||||||
| NPI: | 1154733483 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAVERY | ||||||||
| FirstName: | KRISTINA | ||||||||
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| Credential: | MS, CAS, NCSP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 E UTICA ST | ||||||||
| Address2: | |||||||||
| City: | OSWEGO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 131262721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154023660 | ||||||||
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| Practice Location | |||||||||
| Address1: | 216 COUNTY ROUTE 64 | ||||||||
| Address2: | |||||||||
| City: | MEXICO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 131143229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3159630864 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2014 | ||||||||
| LastUpdateDate: | 05/21/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TS0200X | 2540134 | NY | Y | Behavioral Health & Social Service Providers | Psychologist | School |
No ID Information.