Healthcare Provider Details

I. General information

NPI: 1710842406
Provider Name (Legal Business Name): MORGAN VICTORIA WILD BROST LPA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 W HIGHWAY 146
LA GRANGE KY
40031-9123
US

IV. Provider business mailing address

4803 SYCAMORE RUN DR
LA GRANGE KY
40031-7548
US

V. Phone/Fax

Practice location:
  • Phone: 502-222-9441
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number252557
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: