Healthcare Provider Details

I. General information

NPI: 1083902191
Provider Name (Legal Business Name): KVC BEHAVIORAL HEALTHCARE KENTUCKY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2011
Last Update Date: 05/21/2021
Certification Date: 05/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 THUNDERSTICK DR STE 1104
LEXINGTON KY
40505-9009
US

IV. Provider business mailing address

2250 THUNDERSTICK DR STE 1104
LEXINGTON KY
40505-9009
US

V. Phone/Fax

Practice location:
  • Phone: 859-254-1035
  • Fax: 859-254-2075
Mailing address:
  • Phone: 859-254-1035
  • Fax: 859-254-2075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number StateKY

VIII. Authorized Official

Name: REGINA MARIA KLYACHKIN
Title or Position: AUTHORIZED OFFICIAL/PRESIDENT
Credential:
Phone: 913-322-4900