Healthcare Provider Details

I. General information

NPI: 1184208696
Provider Name (Legal Business Name): SURYA MENTAL WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2021
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1939 GOLDSMITH LN STE 260
LOUISVILLE KY
40218-3174
US

IV. Provider business mailing address

1939 GOLDSMITH LN STE 260
LOUISVILLE KY
40218-3174
US

V. Phone/Fax

Practice location:
  • Phone: 502-519-7979
  • Fax: 502-792-7274
Mailing address:
  • Phone: 502-519-7979
  • Fax: 502-792-7274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: NORMA THOMAS
Title or Position: BILINGUAL CLINICIAN
Credential: LPCA, CVE, M.ED.
Phone: 502-519-7979