Provider Demographics
NPI:1811534647
Name:T.A.V.E.R.N. HEALTH AND WELLNESS, LLC
Entity type:Organization
Organization Name:T.A.V.E.R.N. HEALTH AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:GAYLA
Authorized Official - Middle Name:R
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:314-385-9550
Mailing Address - Street 1:5517 ALBIA TERR
Mailing Address - Street 2:
Mailing Address - City:JENNINGS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-1222
Mailing Address - Country:US
Mailing Address - Phone:314-385-9550
Mailing Address - Fax:
Practice Address - Street 1:11042 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-1244
Practice Address - Country:US
Practice Address - Phone:314-385-9550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-27
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty
No174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty