Healthcare Provider Details

I. General information

NPI: 1295937134
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: 02/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 FARRELL DRIVE
COVINGTON KY
41011
US

IV. Provider business mailing address

503 FARRELL DRIVE
COVINGTON KY
41011
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number800084
License Number StateKY

VIII. Authorized Official

Name: OWEN T NICHOLS
Title or Position: CEO
Credential: PSY.D
Phone: 859-578-3252