Basic Information
| Provider Information | |||||||||
| NPI: | 1902225543 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAVIGNE | ||||||||
| FirstName: | ALISSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3111 S DIXIE HWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334051548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616126062 | ||||||||
| FaxNumber: | 5616126095 | ||||||||
| Practice Location | |||||||||
| Address1: | 3111 S DIXIE HWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334051548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616126045 | ||||||||
| FaxNumber: | 5616126095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2014 | ||||||||
| LastUpdateDate: | 01/03/2017 | ||||||||
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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 | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 010893100 | 05 | FL | MEDICAID |