Provider Demographics
NPI:1568028140
Name:RIVERSIDE THERAPY LLC
Entity Type:Organization
Organization Name:RIVERSIDE THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:907-987-5088
Mailing Address - Street 1:250 CUSHMAN ST STE 4F
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4665
Mailing Address - Country:US
Mailing Address - Phone:907-987-5088
Mailing Address - Fax:
Practice Address - Street 1:250 CUSHMAN ST STE 4F
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4665
Practice Address - Country:US
Practice Address - Phone:907-987-5088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-19
Last Update Date:2019-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)