Healthcare Provider Details

I. General information

NPI: 1366197147
Provider Name (Legal Business Name): BLUEGRASS COUNSELING & TRAUMA SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2022
Last Update Date: 04/09/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 DARBY CREEK RD STE C
LEXINGTON KY
40509-1603
US

IV. Provider business mailing address

503 DARBY CREEK RD STE C
LEXINGTON KY
40509-1603
US

V. Phone/Fax

Practice location:
  • Phone: 859-368-2567
  • Fax: 859-788-3905
Mailing address:
  • Phone: 859-368-2567
  • Fax: 859-788-3905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: CRYSTAL STAPLETON
Title or Position: CONTRACTING DIRECTOR
Credential:
Phone: 270-380-1093