Provider Demographics
NPI:1093131948
Name:RUDOLPH VON RAVENSBERG
Entity Type:Organization
Organization Name:RUDOLPH VON RAVENSBERG
Other - Org Name:GREAT BASIN BEHAVIORAL HEALTH AND WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PSYCHOTHERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUDOLPH
Authorized Official - Middle Name:
Authorized Official - Last Name:VON RAVENSBERG
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:775-232-0399
Mailing Address - Street 1:1325 AIRMOTIVE WAY
Mailing Address - Street 2:STE 175R
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-3275
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1325 AIRMOTIVE WAY
Practice Address - Street 2:STE 175R
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-3275
Practice Address - Country:US
Practice Address - Phone:775-453-4143
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-14
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1098106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1184822520OtherNPI