Healthcare Provider Details

I. General information

NPI: 1497946529
Provider Name (Legal Business Name): LARRY SPRINGATE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 08/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 WIND HAVEN DR #202
NICHOLASVILLE KY
40356-8035
US

IV. Provider business mailing address

101 WIND HAVEN DR #202
NICHOLASVILLE KY
40356-8035
US

V. Phone/Fax

Practice location:
  • Phone: 859-277-0022
  • Fax: 859-277-0077
Mailing address:
  • Phone: 859-277-0022
  • Fax: 859-277-0077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1082
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0432
License Number StateKY

VIII. Authorized Official

Name: DR. LARRY G SPRINGATE
Title or Position: OWNER
Credential: PSYD
Phone: 859-277-0022