MEDICARE: MICHAEL LAVERDIERE BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106E00000X	Assistant Behavior Analyst	09-19-10548	MN
2	106S00000X	Behavior Technician	RBT-18-62994	MI
3	103K00000X	Behavior Analyst	1-20-42370	MN

General Provider Information

NPI Number	:	1710539473
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL LAVERDIERE BCBA

Provider Business Mailing Address
First Line	:	2804 E 26TH ST STE 1
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57103-4019
Country	:	US
Telephone Number	:	605-271-2690
Fax Number	:	605-271-3956

Provider Business Practice Location Address
First Line	:	3721 23RD ST S APT 201
Second Line	:
City	:	SAINT CLOUD
State	:	MN
Zip	:	56301-6199
Country	:	US
Telephone Number	:	218-457-2185
Fax Number	:	605-271-3956

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2019
Last Update Date	:	06/03/2020

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