Provider Demographics
NPI:1528106457
Name:LAVALLE, MICHAEL ROBERT (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ROBERT
Last Name:LAVALLE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7557 RAMBLER RD STE 430
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-2378
Mailing Address - Country:US
Mailing Address - Phone:214-750-1086
Mailing Address - Fax:214-750-1971
Practice Address - Street 1:7557 RAMBLER RD STE 430
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-2378
Practice Address - Country:US
Practice Address - Phone:214-750-1086
Practice Address - Fax:214-750-1971
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23462103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
75-2362687OtherTAX ID
41699OtherHEALTH SEVICE PROVIDER
TX2-3462OtherSTATE LICENSE