Healthcare Provider Details

I. General information

NPI: 1679389332
Provider Name (Legal Business Name): ALLEGIANCE TO SELF
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2024
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3711 W BROADWAY
LOUISVILLE KY
40211-2847
US

IV. Provider business mailing address

9508 YELLOW PINE CT
LOUISVILLE KY
40229-1642
US

V. Phone/Fax

Practice location:
  • Phone: 502-322-2065
  • Fax:
Mailing address:
  • Phone: 502-322-2065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. ANTWONE SHAW
Title or Position: CEO
Credential:
Phone: 502-322-2065