Provider Demographics
NPI:1215673082
Name:LAFOLLETTE, JOHN WILLIAM (LAC, MATS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:WILLIAM
Last Name:LAFOLLETTE
Suffix:
Gender:M
Credentials:LAC, MATS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4705 MEIJER CT
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-4684
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2374 SHAKER LN APT E
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052-4100
Practice Address - Country:US
Practice Address - Phone:317-797-0773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-05
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN86000408A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)