Healthcare Provider Details

I. General information

NPI: 1730419615
Provider Name (Legal Business Name): TROY FESSEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2009
Last Update Date: 06/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4710 CHAMPIONS TRACE LN #107
LOUISVILLE KY
40218-3495
US

IV. Provider business mailing address

101 W MUHAMMAD ALI BLVD
LOUISVILLE KY
40202-1423
US

V. Phone/Fax

Practice location:
  • Phone: 502-589-8600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number104742
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: