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General NPI Number Information
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NPI Number | 1811534647
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Entity Type | Organization
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Legal Business Name | T.A.V.E.R.N. HEALTH AND WELLNESS, LLC
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Dates
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Enumeration Date | 11/27/2019
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Last Update Date | 11/27/2019
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Provider Practice Location Address
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Address Line | 11042 MANCHESTER RD
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City | KIRKWOOD
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State | MO
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Zip | 63122-1244
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Country | US
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Telephone | 314-385-9550
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Fax |
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Provider Business Mailing Address
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Address Line | 5517 ALBIA TERR
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City | JENNINGS
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State | MO
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Zip | 63136-1222
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Country | US
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Telephone | 314-385-9550
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Fax |
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Authorized Official
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Title or Position | THERAPIST
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Name | GAYLA R GIBSON
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Credential | MA, LPC
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Telephone | 314-385-9550
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133NN1002X
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Taxonomy Name | Nutrition Education Nutritionist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 174H00000X
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Taxonomy Name | Health Educator
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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