Healthcare Provider Details

I. General information

NPI: 1033005079
Provider Name (Legal Business Name): MINDCLUB KENTUCKY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2025
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 DERRICK PL
HOPKINSVILLE KY
42240-1325
US

IV. Provider business mailing address

106 MISSION CT STE 201A
FRANKLIN TN
37067-6441
US

V. Phone/Fax

Practice location:
  • Phone: 833-833-9655
  • Fax:
Mailing address:
  • Phone: 153-902-8656
  • Fax:

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 Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KATHY RICHARDSON
Title or Position: VP, CAO
Credential:
Phone: 615-390-2865