Provider Demographics
NPI:1538684261
Name:IVERY, LARRY ANTHONY SR (LPC-MHSP)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:ANTHONY
Last Name:IVERY
Suffix:SR
Gender:M
Credentials:LPC-MHSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 FRANK LATHAM
Mailing Address - Street 2:170 FRANK LATHAM
Mailing Address - City:PINSON
Mailing Address - State:TN
Mailing Address - Zip Code:38366
Mailing Address - Country:US
Mailing Address - Phone:731-989-7335
Mailing Address - Fax:731-989-7288
Practice Address - Street 1:170 FRANK LATHAM RD
Practice Address - Street 2:
Practice Address - City:PINSON
Practice Address - State:TN
Practice Address - Zip Code:38366-9632
Practice Address - Country:US
Practice Address - Phone:731-989-7335
Practice Address - Fax:731-989-7288
Is Sole Proprietor?:No
Enumeration Date:2017-08-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3964101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1043663495Medicaid