Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 102L00000X | Psychologist | 972 | MT |
N | 103T00000X | Psychologist | 972 | MT |
Y | 102L00000X | Psychologist | PSY-203139 | ID |
Y | 103T00000X | Psychologist | PSY-203139 | ID |
NPI | 1013247097 |
---|---|
Provider Name | Dr. Christopher D Laviola |
First Address | Dalton Gardens, ID 83815-9514 |
Second Address | Dalton Gardens, ID 83815-9514 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/01/2010 |
Last Update Date | 03/12/2021 |