Healthcare Provider Details

I. General information

NPI: 1932590338
Provider Name (Legal Business Name): KENTUCKY COUNSELING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2015
Last Update Date: 08/26/2022
Certification Date: 08/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1169 EASTERN PKWY STE 3328
LOUISVILLE KY
40217-1415
US

IV. Provider business mailing address

PO BOX 701059 PMB 50499
LOUISVILLE KY
40270
US

V. Phone/Fax

Practice location:
  • Phone: 855-591-0092
  • Fax: 502-631-9660
Mailing address:
  • Phone: 855-591-0092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number216680
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number216680
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number216680
License Number StateKY

VIII. Authorized Official

Name: KAYLEE PHELPS
Title or Position: VICE PRESIDENT OF HUMAN RESOURCES
Credential:
Phone: 859-625-4663