Healthcare Provider Details

I. General information

NPI: 1265858864
Provider Name (Legal Business Name): R.E.A.C.H. PROGRAM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2014
Last Update Date: 01/24/2024
Certification Date: 01/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 W STEPHEN FOSTER AVE STE 113
BARDSTOWN KY
40004-1457
US

IV. Provider business mailing address

120 W STEPHEN FOSTER AVE STE 113
BARDSTOWN KY
40004-1457
US

V. Phone/Fax

Practice location:
  • Phone: 502-350-7368
  • Fax:
Mailing address:
  • Phone: 502-350-7368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: STACIE A SYLVESTER
Title or Position: MEMBER
Credential: LCSW LCADC
Phone: 502-350-7368