Healthcare Provider Details

I. General information

NPI: 1851998181
Provider Name (Legal Business Name): SPECIALISTSMAT PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2020
Last Update Date: 11/17/2025
Certification Date: 11/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 CHASE WAY STE 2
ELIZABETHTOWN KY
42701-7827
US

IV. Provider business mailing address

110 CHASE WAY STE 2
ELIZABETHTOWN KY
42701-7827
US

V. Phone/Fax

Practice location:
  • Phone: 502-212-0071
  • Fax: 502-530-5303
Mailing address:
  • Phone: 502-212-0071
  • Fax: 502-996-8359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207LA0401X
TaxonomyAddiction Medicine (Anesthesiology) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CARA NICOLE NETHERTON
Title or Position: PRACTICE MANAGER
Credential:
Phone: 502-212-0071