Healthcare Provider Details

I. General information

NPI: 1730401498
Provider Name (Legal Business Name): JACQUELINE BAVARO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2010
Last Update Date: 02/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 4TH ST NW STE 5
DEVILS LAKE ND
58301-2960
US

IV. Provider business mailing address

1201 25TH ST S PO BOX 9859
FARGO ND
58103-2311
US

V. Phone/Fax

Practice location:
  • Phone: 701-664-6776
  • Fax: 701-662-6889
Mailing address:
  • Phone: 701-662-6776
  • Fax: 701-662-6889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2975
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: