Provider Demographics
NPI:1659078434
Name:DEVER, GENAVEIVE MARIE
Entity Type:Individual
Prefix:
First Name:GENAVEIVE
Middle Name:MARIE
Last Name:DEVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4515 GRAND LAKE DR STE 101
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44212-4590
Mailing Address - Country:US
Mailing Address - Phone:330-391-2618
Mailing Address - Fax:
Practice Address - Street 1:13377 SMITH RD
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-7810
Practice Address - Country:US
Practice Address - Phone:440-340-5558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0002926175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH175T00000XMedicaid