1477429504 NPI number — MAKING WAVES MUSIC THERAPY LLC

Table of content: RICHARD RUSSELL PROVENCIAL CAS (NPI 1538790134)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477429504 NPI number — MAKING WAVES MUSIC THERAPY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAKING WAVES MUSIC THERAPY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477429504
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5420 BRANDON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILTON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32570-8005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-202-5454
Provider Business Mailing Address Fax Number:
850-378-5230

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7210 DOGWOOD TERRACE DR STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32504-6709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-202-5454
Provider Business Practice Location Address Fax Number:
850-378-5230
Provider Enumeration Date:
10/15/2025

Additional Information

Authorized Official

Authorized Official Last Name:
CONNICK
Authorized Official First Name:
KAYLA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER & PRIMARY THERAPIST
Authorized Official Telephone Number:
702-202-5454

Provider Taxonomy Codes

  • Taxonomy code: 225A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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