Healthcare Provider Details

I. General information

NPI: 1144956848
Provider Name (Legal Business Name): UNNU ENERELT DWENGER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

9810 BLUEGRASS PKWY
LOUISVILLE KY
40299-1906
US

IV. Provider business mailing address

1250 BARDSTOWN ROAD SUITE 15
LOUISVILLE KY
40204
US

V. Phone/Fax

Practice location:
  • Phone: 502-791-9944
  • Fax:
Mailing address:
  • Phone: 502-409-9548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number279206
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: