Healthcare Provider Details

I. General information

NPI: 1891081246
Provider Name (Legal Business Name): GERARD LAWRENCE LAFAVE MA, LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2011
Last Update Date: 06/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58826 OTTER DR
HINCKLEY MN
55037-5355
US

IV. Provider business mailing address

58826 OTTER DR
HINCKLEY MN
55037-5355
US

V. Phone/Fax

Practice location:
  • Phone: 612-240-7647
  • Fax: 320-384-6799
Mailing address:
  • Phone: 612-240-7647
  • Fax: 320-384-6799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number12345
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: