Healthcare Provider Details

I. General information

NPI: 1427471549
Provider Name (Legal Business Name): DAIQUIRI FALLON AMS LPCC-S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2014
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4537 LARGO LN
LEXINGTON KY
40515-5124
US

IV. Provider business mailing address

4537 LARGO LN
LEXINGTON KY
40515-5124
US

V. Phone/Fax

Practice location:
  • Phone: 859-279-2031
  • Fax:
Mailing address:
  • Phone: 859-279-2031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number171234
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: