Healthcare Provider Details

I. General information

NPI: 1669093647
Provider Name (Legal Business Name): LOUISVILLE INTEGRATED CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2020
Last Update Date: 07/09/2020
Certification Date: 07/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 S 4TH ST STE 208
LOUISVILLE KY
40203-3101
US

IV. Provider business mailing address

1151 S 4TH ST STE 208
LOUISVILLE KY
40203-3101
US

V. Phone/Fax

Practice location:
  • Phone: 502-612-6981
  • Fax:
Mailing address:
  • Phone: 502-612-6981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE R HICKS
Title or Position: OWNER
Credential: CADC
Phone: 502-612-6981