Healthcare Provider Details

I. General information

NPI: 1932566544
Provider Name (Legal Business Name): APPALACHIAN WELLNESS, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2016
Last Update Date: 01/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

592 KY 15 SOUTH SUITE 5
CAMPTON KY
41301
US

IV. Provider business mailing address

PO BOX 1136 592 KY 15 SOUTH, SUITE 5
CAMPTON KY
41301-1136
US

V. Phone/Fax

Practice location:
  • Phone: 606-668-7393
  • Fax: 866-718-4137
Mailing address:
  • Phone: 606-668-7393
  • Fax: 866-718-4137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSYPPR00216468
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number41931
License Number StateKY

VIII. Authorized Official

Name: SHERI LYN ROSE HAAS
Title or Position: OWNER
Credential: M.A., L.P.P.
Phone: 606-668-7393