Healthcare Provider Details

I. General information

NPI: 1376376400
Provider Name (Legal Business Name): SHELBY GRACE YEICH MA, LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2024
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3150 CUSTER DR STE 202
LEXINGTON KY
40517-4010
US

IV. Provider business mailing address

3150 CUSTER DR STE 202
LEXINGTON KY
40517-4010
US

V. Phone/Fax

Practice location:
  • Phone: 502-219-3488
  • Fax:
Mailing address:
  • Phone: 502-219-3488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number294221
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: