Provider Demographics
NPI:1053717991
Name:PALM, LAVATTA CARLETTE
Entity type:Individual
Prefix:
First Name:LAVATTA
Middle Name:CARLETTE
Last Name:PALM
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 1:4792 E UTAH AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-5926
Mailing Address - Country:US
Mailing Address - Phone:702-583-8805
Mailing Address - Fax:
Practice Address - Street 1:6080 S FORT APACHE RD STE 105
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-5616
Practice Address - Country:US
Practice Address - Phone:702-588-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-04
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCHW2-5007172V00000X
NV07537-1101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No172V00000XOther Service ProvidersCommunity Health Worker