Provider Demographics
NPI:1629401567
Name:LAVER JUANTO, MARIAH DAWN (PHD)
Entity type:Individual
Prefix:DR
First Name:MARIAH
Middle Name:DAWN
Last Name:LAVER JUANTO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:MARIAH
Other - Middle Name:DAWN
Other - Last Name:LAVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2100 S COLUMBIA RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-5895
Mailing Address - Country:US
Mailing Address - Phone:701-772-1588
Mailing Address - Fax:
Practice Address - Street 1:2100 S COLUMBIA RD
Practice Address - Street 2:SUITE 202
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-5895
Practice Address - Country:US
Practice Address - Phone:701-772-1588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-14
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist