Healthcare Provider Details

I. General information

NPI: 1720946247
Provider Name (Legal Business Name): BOULWARE MISSION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 WING AVE
OWENSBORO KY
42303-0408
US

IV. Provider business mailing address

609 WING AVE
OWENSBORO KY
42303-0408
US

V. Phone/Fax

Practice location:
  • Phone: 270-683-8267
  • Fax:
Mailing address:
  • Phone: 270-683-8267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. SHANE SHERIFF
Title or Position: CLINICAL DIRECTOR
Credential: LCADC, LPCC, CCS
Phone: 270-683-8267