Healthcare Provider Details

I. General information

NPI: 1154193563
Provider Name (Legal Business Name): DEVELOPMENT ACADEMY CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2023
Last Update Date: 10/27/2023
Certification Date: 10/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

537 DR W J HODGE ST
LOUISVILLE KY
40203-1561
US

IV. Provider business mailing address

2414 ARTHUR ST
JEFFERSONVILLE IN
47130-9577
US

V. Phone/Fax

Practice location:
  • Phone: 502-802-3070
  • Fax:
Mailing address:
  • Phone: 502-910-1117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name: GERAIL PICKETT
Title or Position: ADVISOR
Credential: B.S.
Phone: 502-802-3070