Healthcare Provider Details

I. General information

NPI: 1114005840
Provider Name (Legal Business Name): RENIVA JO S. AVERY M.A. EL.ED.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 03/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3770 DEFRIES RD
CANMER KY
42722
US

IV. Provider business mailing address

3770 DEFRIES RD
CANMER KY
42722-9461
US

V. Phone/Fax

Practice location:
  • Phone: 270-528-4416
  • Fax: 270-528-4417
Mailing address:
  • Phone: 270-528-4416
  • Fax: 270-528-4417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License NumberF254TZ
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: