Healthcare Provider Details

I. General information

NPI: 1538084785
Provider Name (Legal Business Name): DIVER VAN AVERY MFA, MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 W LAKE ST STE 350
MINNEAPOLIS MN
55408-2952
US

IV. Provider business mailing address

621 W LAKE ST STE 350
MINNEAPOLIS MN
55408-2952
US

V. Phone/Fax

Practice location:
  • Phone: 612-979-2276
  • Fax: 651-925-0427
Mailing address:
  • Phone: 612-979-2276
  • Fax: 651-925-0427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5755
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: