Provider Demographics
NPI:1154733483
Name:LAVERY, KRISTINA (MS, CAS, NCSP)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:LAVERY
Suffix:
Gender:F
Credentials:MS, CAS, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 E UTICA ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-2721
Mailing Address - Country:US
Mailing Address - Phone:315-402-3660
Mailing Address - Fax:
Practice Address - Street 1:216 COUNTY ROUTE 64
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:NY
Practice Address - Zip Code:13114-3229
Practice Address - Country:US
Practice Address - Phone:315-963-0864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-21
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2540134103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool