Provider Demographics
NPI:1912033051
Name:LAVALLEY, WILLLIAM JAY (LMSW)
Entity type:Individual
Prefix:MR
First Name:WILLLIAM
Middle Name:JAY
Last Name:LAVALLEY
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 S WESTNEDGE AVE # 2
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-1110
Mailing Address - Country:US
Mailing Address - Phone:269-744-5293
Mailing Address - Fax:269-382-0064
Practice Address - Street 1:914 S WESTNEDGE AVE # 2
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-1110
Practice Address - Country:US
Practice Address - Phone:269-744-5293
Practice Address - Fax:269-382-0064
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010847911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI11563655OtherCACQ
MI32186Medicaid
MI0P29740Medicare ID - Type Unspecified