1538684261 NPI number — DR. LARRY ANTHONY IVERY SR. LPC-MHSP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538684261 NPI number — DR. LARRY ANTHONY IVERY SR. LPC-MHSP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IVERY
Provider First Name:
LARRY
Provider Middle Name:
ANTHONY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
SR.
Provider Credential Text:
LPC-MHSP
Provider Gender Code:
M

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:
1538684261
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
170 FRANK LATHAM
Provider Second Line Business Mailing Address:
170 FRANK LATHAM
Provider Business Mailing Address City Name:
PINSON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38366
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-989-7335
Provider Business Mailing Address Fax Number:
731-989-7288

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
170 FRANK LATHAM RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINSON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38366-9632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-989-7335
Provider Business Practice Location Address Fax Number:
731-989-7288
Provider Enumeration Date:
08/03/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  3964 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1043663495 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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