Provider Demographics
NPI:1083284814
Name:ITAVIA'S HOUSE OF CARE LLC
Entity Type:Organization
Organization Name:ITAVIA'S HOUSE OF CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC-MHSP,
Authorized Official - Phone:615-905-6321
Mailing Address - Street 1:10543 CEDAR GROVE RD STE 150
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-6525
Mailing Address - Country:US
Mailing Address - Phone:615-905-6321
Mailing Address - Fax:
Practice Address - Street 1:10543 CEDAR GROVE RD STE 150
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-6525
Practice Address - Country:US
Practice Address - Phone:615-905-6321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-24
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ034586Medicaid