Provider Demographics
NPI:1508279746
Name:EDWARDS AND VON RAVENSBERG, PROF. LLC
Entity Type:Organization
Organization Name:EDWARDS AND VON RAVENSBERG, PROF. LLC
Other - Org Name:GREAT BASIN BEHAVIORAL HEALTH AND WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:RUDOLPH
Authorized Official - Middle Name:
Authorized Official - Last Name:VON RAVENSBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:775-453-4143
Mailing Address - Street 1:1325 AIRMOTIVE WAY
Mailing Address - Street 2:STE 100
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-3201
Mailing Address - Country:US
Mailing Address - Phone:775-453-4143
Mailing Address - Fax:775-996-5616
Practice Address - Street 1:1325 AIRMOTIVE WAY
Practice Address - Street 2:STE 100
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-3201
Practice Address - Country:US
Practice Address - Phone:775-453-4143
Practice Address - Fax:775-996-5616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-05
Last Update Date:2015-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV MFT 1098251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health