Healthcare Provider Details

I. General information

NPI: 1891606190
Provider Name (Legal Business Name): INNERBALANCE DIAGNOSIS CENTER KY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 EXECUTIVE DR STE 101
LEXINGTON KY
40505-4871
US

IV. Provider business mailing address

501 W WILLIAMS ST UNIT 1036
APEX NC
27502-2297
US

V. Phone/Fax

Practice location:
  • Phone: 859-765-6825
  • Fax: 919-935-0858
Mailing address:
  • Phone: 984-319-7357
  • Fax: 919-935-0858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SHIRLEYJO LEE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 984-319-7357