MEDICARE: JACQUELINE BAVARO

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	101YM0800X	Mental Health Counselor	2975	ND

General Provider Information

NPI Number	:	1730401498
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE BAVARO

Provider Business Mailing Address
First Line	:	1201 25TH ST S
Second Line	:	PO BOX 9859
City	:	FARGO
State	:	ND
Zip	:	58103-2311
Country	:	US
Telephone Number	:	701-662-6776
Fax Number	:	701-662-6889

Provider Business Practice Location Address
First Line	:	224 4TH ST NW STE 5
Second Line	:
City	:	DEVILS LAKE
State	:	ND
Zip	:	58301-2960
Country	:	US
Telephone Number	:	701-664-6776
Fax Number	:	701-662-6889

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

Provider Enumeration Date	:	02/23/2010
Last Update Date	:	02/23/2010

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Directions to “ JACQUELINE BAVARO ” Practice Location

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