Healthcare Provider Details

I. General information

NPI: 1730363862
Provider Name (Legal Business Name): RESOURCES FOR EDUCATION, ADAPTATION, CHANGE, AND HEALTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2007
Last Update Date: 05/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 PARK AVE
LOUISVILLE KY
40208-2318
US

IV. Provider business mailing address

501 PARK AVE
LOUISVILLE KY
40208-2318
US

V. Phone/Fax

Practice location:
  • Phone: 502-585-1911
  • Fax: 501-589-1582
Mailing address:
  • Phone: 502-585-1911
  • Fax: 501-589-1582

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 StateKY
# 3
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number500165
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateKY

VIII. Authorized Official

Name: DR. ROBERT JOHN ILLBACK
Title or Position: CEO
Credential: PSYD
Phone: 502-585-1911