Healthcare Provider Details

I. General information

NPI: 1417585498
Provider Name (Legal Business Name): TONYA MARIE MARAVILLA APSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 07/25/2026
Certification Date: 07/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 E DIXIE AVE STE 106
ELIZABETHTOWN KY
42701-1162
US

IV. Provider business mailing address

413 E DIXIE AVE STE 106
ELIZABETHTOWN KY
42701-1162
US

V. Phone/Fax

Practice location:
  • Phone: 270-319-9899
  • Fax:
Mailing address:
  • Phone: 270-319-9899
  • Fax: 270-305-3253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number275316
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number1170044
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberTC00001083
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: