Provider Demographics
NPI:1770234502
Name:HAVERLAND, ALEXIS
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:HAVERLAND
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 1:647 13TH AVE E
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-3328
Mailing Address - Country:US
Mailing Address - Phone:701-277-8844
Mailing Address - Fax:
Practice Address - Street 1:203 NEUMAN BLVD
Practice Address - Street 2:
Practice Address - City:COLFAX
Practice Address - State:ND
Practice Address - Zip Code:58018-2812
Practice Address - Country:US
Practice Address - Phone:701-640-6898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-13
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NDBACB756230103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician