Provider Demographics
NPI:1639843303
Name:KOANN THERAPEUTIC SERVICES INC
Entity Type:Organization
Organization Name:KOANN THERAPEUTIC SERVICES INC
Other - Org Name:REVIVE THERAPEUTIC SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:AKOS
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTWI
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP, PMHNP-BC
Authorized Official - Phone:401-648-7172
Mailing Address - Street 1:PO BOX 3085
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02861-0585
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:382 THAYER ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-1558
Practice Address - Country:US
Practice Address - Phone:401-648-7172
Practice Address - Fax:401-648-0161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-05
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)