Healthcare Provider Details

I. General information

NPI: 1679775514
Provider Name (Legal Business Name): NORTHERN KENTUCKY MENTAL HEALTH MENTAL RETARDATION REGIONAL BOARD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 05/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 FARRELL DR
COVINGTON KY
41011-3775
US

IV. Provider business mailing address

503 FARRELL DR
COVINGTON KY
41011-3775
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number800084
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code364SP0812X
TaxonomyCommunity Psychiatric/Mental Health Clinical Nurse Specialist
License Number800084
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number100265
License Number StateKY

VIII. Authorized Official

Name: OWEN T NICHOLS
Title or Position: PRESIDENT
Credential: PSY.D.
Phone: 859-578-3200