Healthcare Provider Details

I. General information

NPI: 1023778594
Provider Name (Legal Business Name): NORTHERN KENTUCKY BEHAVIORAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2021
Last Update Date: 04/29/2022
Certification Date: 04/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2335 STERLINGTON RD STE 100
LEXINGTON KY
40517-3937
US

IV. Provider business mailing address

820 DOLWICK DR
ERLANGER KY
41018-2774
US

V. Phone/Fax

Practice location:
  • Phone: 859-466-0115
  • Fax: 859-578-2875
Mailing address:
  • Phone: 859-466-0115
  • Fax: 859-578-2875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number
License Number State

VIII. Authorized Official

Name: TOM ROURKE ROURKE
Title or Position: SENIOR VICE PRESIDENT CORPORATE DEV
Credential:
Phone: 197-246-7446