Healthcare Provider Details

I. General information

NPI: 1811534647
Provider Name (Legal Business Name): T.A.V.E.R.N. HEALTH AND WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2019
Last Update Date: 11/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11042 MANCHESTER RD
KIRKWOOD MO
63122-1244
US

IV. Provider business mailing address

5517 ALBIA TERR
JENNINGS MO
63136-1222
US

V. Phone/Fax

Practice location:
  • Phone: 314-385-9550
  • Fax:
Mailing address:
  • Phone: 314-385-9550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name: GAYLA R GIBSON
Title or Position: THERAPIST
Credential: MA, LPC
Phone: 314-385-9550