Provider Demographics
NPI:1033802939
Name:ANIVANA THERAPEUTIC SERVICES
Entity Type:Organization
Organization Name:ANIVANA THERAPEUTIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ROCHELLE
Authorized Official - Middle Name:JACQUELYN
Authorized Official - Last Name:RAINVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:719-315-0728
Mailing Address - Street 1:4370 E PIKES PEAK AVE APT 217
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-6771
Mailing Address - Country:US
Mailing Address - Phone:949-370-0383
Mailing Address - Fax:
Practice Address - Street 1:4390 N ACADEMY BLVD STE 101B
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-6626
Practice Address - Country:US
Practice Address - Phone:719-315-0728
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-29
Last Update Date:2023-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)