Healthcare Provider Details

I. General information

NPI: 1184592701
Provider Name (Legal Business Name): BLUEGRASS ADVANCED MENTAL HEALTH, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4642 CHAMBERLAIN LN
LOUISVILLE KY
40241-2156
US

IV. Provider business mailing address

8222 SPRING GLADE PL
PROSPECT KY
40059-7653
US

V. Phone/Fax

Practice location:
  • Phone: 502-208-9003
  • Fax:
Mailing address:
  • Phone: 808-741-3031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID ERICH ROTH
Title or Position: OWNER
Credential:
Phone: 808-741-3031