Healthcare Provider Details

I. General information

NPI: 1164038295
Provider Name (Legal Business Name): KARISSA MUELLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2020
Last Update Date: 09/23/2020
Certification Date: 09/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 MADISON AVE
COVINGTON KY
41011-3330
US

IV. Provider business mailing address

1717 MADISON AVE
COVINGTON KY
41011-3330
US

V. Phone/Fax

Practice location:
  • Phone: 859-360-0254
  • Fax: 859-261-0801
Mailing address:
  • Phone: 859-360-0254
  • Fax: 859-261-0801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number264708
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: