Healthcare Provider Details

I. General information

NPI: 1518235183
Provider Name (Legal Business Name): DBT CENTER OF WESTERN KENTUCKY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2011
Last Update Date: 01/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 ANDREA ST SUITE 205
BOWLING GREEN KY
42104-3382
US

IV. Provider business mailing address

1300 ANDREA ST SUITE 205
BOWLING GREEN KY
42104-3382
US

V. Phone/Fax

Practice location:
  • Phone: 270-904-2260
  • Fax: 270-781-9680
Mailing address:
  • Phone: 270-904-2260
  • Fax: 270-781-9680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: JOSHUA M SMITH
Title or Position: OWNER
Credential: LMSW BCD
Phone: 270-904-2260