Provider Demographics
NPI:1760296446
Name:LAFAVE, MARK (HAD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:LAFAVE
Suffix:
Gender:M
Credentials:HAD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2156 N HILL FIELD RD STE 3
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-4771
Mailing Address - Country:US
Mailing Address - Phone:801-203-4055
Mailing Address - Fax:
Practice Address - Street 1:111 S 24TH ST W UNIT 7
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-5659
Practice Address - Country:US
Practice Address - Phone:406-248-1006
Practice Address - Fax:406-324-9222
Is Sole Proprietor?:No
Enumeration Date:2025-02-04
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTHAD-HAD-LIC-1734237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist