Provider Demographics
NPI:1275702615
Name:TAVERNER, ROBERT RUSSELL (LCMFT)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:RUSSELL
Last Name:TAVERNER
Suffix:
Gender:M
Credentials:LCMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:787 AVENUE N
Mailing Address - Street 2:
Mailing Address - City:CHASE
Mailing Address - State:KS
Mailing Address - Zip Code:67524-9462
Mailing Address - Country:US
Mailing Address - Phone:620-938-9949
Mailing Address - Fax:
Practice Address - Street 1:787 AVENUE N
Practice Address - Street 2:
Practice Address - City:CHASE
Practice Address - State:KS
Practice Address - Zip Code:67524-9462
Practice Address - Country:US
Practice Address - Phone:620-938-9949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-28
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS134106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist