Healthcare Provider Details

I. General information

NPI: 1922696863
Provider Name (Legal Business Name): GUSTAVO ALCANTARA OCAMPO LPCA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2021
Last Update Date: 12/28/2022
Certification Date: 12/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 HOPE ST
MT WASHINGTON KY
40047-7757
US

IV. Provider business mailing address

1351 NEWTOWN PIKE BLDG 1
LEXINGTON KY
40511-1277
US

V. Phone/Fax

Practice location:
  • Phone: 502-538-1000
  • Fax:
Mailing address:
  • Phone: 859-253-1686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number265677
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: