Basic Information
| Provider Information | |||||||||
| NPI: | 1588653372 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAVIN | ||||||||
| FirstName: | ANITA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1234 WHITEFISH STAGE | ||||||||
| Address2: | |||||||||
| City: | KALISPELL | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599012753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067567878 | ||||||||
| FaxNumber: | 4062577811 | ||||||||
| Practice Location | |||||||||
| Address1: | 1234 WHITEFISH STAGE | ||||||||
| Address2: | |||||||||
| City: | KALISPELL | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599012753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067567878 | ||||||||
| FaxNumber: | 4062577811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 415PT | MT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0197809 | 01 | MT | PROVIDER # | OTHER | 0343343 | 05 | MT | MEDICAID | 61105 | 01 | MT | PROVIDER # | OTHER |