Basic Information
| Provider Information | |||||||||
| NPI: | 1497086565 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBINSON | ||||||||
| FirstName: | LAVELL | ||||||||
| MiddleName: | TERAN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MASTERS OF SCIENCE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 E ADELAIDE WAY | ||||||||
| Address2: | |||||||||
| City: | DINUBA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936181758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5595916800 | ||||||||
| FaxNumber: | 5595916800 | ||||||||
| Practice Location | |||||||||
| Address1: | 3467 W SHAW AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937113223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592713096 | ||||||||
| FaxNumber: | 5592740292 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2010 | ||||||||
| LastUpdateDate: | 01/04/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP1600X | CA | N | Behavioral Health & Social Service Providers | Counselor | Pastoral | 101YM0800X | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | CA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | WI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 1497086565 | 05 | CA | MEDICAID |