Healthcare Provider Details

I. General information

NPI: 1083284814
Provider Name (Legal Business Name): ITAVIA'S HOUSE OF CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2021
Last Update Date: 06/10/2022
Certification Date: 05/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10543 CEDAR GROVE RD STE 150
SMYRNA TN
37167-6525
US

IV. Provider business mailing address

10543 CEDAR GROVE RD STE 150
SMYRNA TN
37167-6525
US

V. Phone/Fax

Practice location:
  • Phone: 615-905-6321
  • Fax:
Mailing address:
  • Phone: 615-905-6321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. ALICIA MICHELLE ELLIS
Title or Position: OWNER/CEO
Credential: LPC-MHSP,
Phone: 615-905-6321