Provider Demographics
NPI:1992529903
Name:LAVENDER, ANKITA
Entity type:Individual
Prefix:
First Name:ANKITA
Middle Name:
Last Name:LAVENDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9471 BRENTWOOD DR APT 79
Mailing Address - Street 2:
Mailing Address - City:LA VISTA
Mailing Address - State:NE
Mailing Address - Zip Code:68128-8227
Mailing Address - Country:US
Mailing Address - Phone:904-635-7031
Mailing Address - Fax:
Practice Address - Street 1:11071 W MAPLE RD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68164-2604
Practice Address - Country:US
Practice Address - Phone:402-932-8884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-14
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE14097101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty