Healthcare Provider Details

I. General information

NPI: 1306274600
Provider Name (Legal Business Name): NILS-ERIK JUHANI JUANTO LAVER PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: NILS-ERIK JUHANI JUANTO PHD

II. Dates (important events)

Enumeration Date: 10/23/2013
Last Update Date: 10/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 4TH ST S
FARGO ND
58103-1914
US

IV. Provider business mailing address

510 4TH ST S
FARGO ND
58103-1914
US

V. Phone/Fax

Practice location:
  • Phone: 701-476-7200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: