Healthcare Provider Details

I. General information

NPI: 1174065627
Provider Name (Legal Business Name): MARY NEBERGALL LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2016
Last Update Date: 01/26/2024
Certification Date: 01/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

513 MADISON AVE
COVINGTON KY
41011-1505
US

IV. Provider business mailing address

502 FARRELL DR
COVINGTON KY
41011-3717
US

V. Phone/Fax

Practice location:
  • Phone: 859-578-3200
  • Fax:
Mailing address:
  • Phone: 859-578-3204
  • Fax: 859-578-3273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number248448
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number260363
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number248448
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: