Healthcare Provider Details

I. General information

NPI: 1174129910
Provider Name (Legal Business Name): TRYSTANNEI COOL CSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRYS COOL CSW

II. Dates (important events)

Enumeration Date: 12/08/2020
Last Update Date: 09/03/2025
Certification Date: 09/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

496 SOUTHLAND DR
LEXINGTON KY
40503-1827
US

IV. Provider business mailing address

496 SOUTHLAND DR
LEXINGTON KY
40503-1827
US

V. Phone/Fax

Practice location:
  • Phone: 859-288-2425
  • Fax:
Mailing address:
  • Phone: 859-288-2425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number259071
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-146922
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: