Provider Demographics
NPI:1013184837
Name:KLEVEN, MARYANNE (OTRL)
Entity Type:Individual
Prefix:
First Name:MARYANNE
Middle Name:
Last Name:KLEVEN
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8201 W BORDON CT
Mailing Address - Street 2:
Mailing Address - City:RATHDRUM
Mailing Address - State:ID
Mailing Address - Zip Code:83858-6496
Mailing Address - Country:US
Mailing Address - Phone:208-651-5505
Mailing Address - Fax:
Practice Address - Street 1:500 W AQUA AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-7764
Practice Address - Country:US
Practice Address - Phone:208-762-1122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-12
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-731174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist