Provider Demographics
NPI:1871927822
Name:LAVELY, WILLIAM T (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:T
Last Name:LAVELY
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 SPRING STREET
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-3554
Mailing Address - Country:US
Mailing Address - Phone:812-901-6881
Mailing Address - Fax:812-218-9318
Practice Address - Street 1:1507 SPRING STREET
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3554
Practice Address - Country:US
Practice Address - Phone:812-901-6881
Practice Address - Fax:812-218-9318
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-27
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004684A363LP0808X
KY3008244363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1063415297OtherGROUP NUMBER - PARK VIEW MD GROUP
1487872636OtherGROUP NUMBER - PARK VIEW ARNP GROUP
IN201198690Medicaid
IN201198690Medicaid
KYK086990Medicare PIN