Provider Demographics
NPI:1346346806
Name:FAVER, RICHARD WILLIAM (MA, LP)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:WILLIAM
Last Name:FAVER
Suffix:
Gender:M
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9640 MARCELLA DR NE
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-7030
Mailing Address - Country:US
Mailing Address - Phone:218-586-2876
Mailing Address - Fax:
Practice Address - Street 1:522 BELTRAMI AVE NW STE 17
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-3182
Practice Address - Country:US
Practice Address - Phone:218-407-2595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 3436103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN43B77FAOtherBCBS OF MN
MN283522300Medicaid