Healthcare Provider Details

I. General information

NPI: 1073724100
Provider Name (Legal Business Name): JOAN LESLIE CLAGETT PASTORAL COUNSELOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

551 WESTPORT RD STE B SUITE 1
ELIZABETHTOWN KY
42701-2950
US

IV. Provider business mailing address

551 WESTPORT RD STE B SUITE 1
ELIZABETHTOWN KY
42701-2950
US

V. Phone/Fax

Practice location:
  • Phone: 270-769-2253
  • Fax: 270-769-0170
Mailing address:
  • Phone: 270-769-2253
  • Fax: 270-769-0170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number0036
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: