Provider Demographics
NPI:1447482641
Name:LAVINE, CHARLES HENRY (LPC-S)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:HENRY
Last Name:LAVINE
Suffix:
Gender:M
Credentials:LPC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 BURCHILL RD N
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76105-3012
Mailing Address - Country:US
Mailing Address - Phone:817-534-0814
Mailing Address - Fax:817-536-1556
Practice Address - Street 1:2701 BURCHILL RD N
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76105-3012
Practice Address - Country:US
Practice Address - Phone:817-534-0814
Practice Address - Fax:817-536-1556
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-20
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13146101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health