Healthcare Provider Details

I. General information

NPI: 1689727224
Provider Name (Legal Business Name): LOUISVILLE INDEPENDENT CASE MANAGEMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 07/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8919 STONE GREEN WAY
LOUISVILLE KY
40220-4073
US

IV. Provider business mailing address

8919 STONE GREEN WAY
LOUISVILLE KY
40220-4073
US

V. Phone/Fax

Practice location:
  • Phone: 502-452-9089
  • Fax: 502-495-7840
Mailing address:
  • Phone: 502-452-9089
  • Fax: 502-495-7840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. AMY WARNER NEWKIRK
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 502-452-9089