Healthcare Provider Details

I. General information

NPI: 1326799081
Provider Name (Legal Business Name): AFFECT PROVIDER GROUP, P.S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2022
Last Update Date: 09/22/2023
Certification Date: 09/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 N 3RD ST STE 3
DANVILLE KY
40422-1691
US

IV. Provider business mailing address

116 N 3RD ST STE 3
DANVILLE KY
40422-1691
US

V. Phone/Fax

Practice location:
  • Phone: 845-769-8758
  • Fax:
Mailing address:
  • Phone: 951-691-9101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KARLA RENEE MULLINGS
Title or Position: DIRECTOR OF COMPLIANCE
Credential: LCADC III
Phone: 845-769-8758