Healthcare Provider Details

I. General information

NPI: 1053916379
Provider Name (Legal Business Name): RACHEL SPENCER IVANOV MSN, APRN, PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2020
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 LANDA ST STE C
NEW BRAUNFELS TX
78130-6163
US

IV. Provider business mailing address

4004 HALFWAY CV
ROUND ROCK TX
78681-1005
US

V. Phone/Fax

Practice location:
  • Phone: 210-360-1590
  • Fax: 210-855-9300
Mailing address:
  • Phone: 512-591-6841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number902941
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1030787
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: