Provider Demographics
NPI:1114005840
Name:AVERY, RENIVA JO S (MA ELED)
Entity Type:Individual
Prefix:MRS
First Name:RENIVA JO
Middle Name:S
Last Name:AVERY
Suffix:
Gender:F
Credentials:MA ELED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3770 DEFRIES RD
Mailing Address - Street 2:
Mailing Address - City:CANMER
Mailing Address - State:KY
Mailing Address - Zip Code:42722-9461
Mailing Address - Country:US
Mailing Address - Phone:270-528-4416
Mailing Address - Fax:270-528-4417
Practice Address - Street 1:3770 DEFRIES RD
Practice Address - Street 2:
Practice Address - City:CANMER
Practice Address - State:KY
Practice Address - Zip Code:42722
Practice Address - Country:US
Practice Address - Phone:270-528-4416
Practice Address - Fax:270-528-4417
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYF254TZ222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist