Healthcare Provider Details

I. General information

NPI: 1831468149
Provider Name (Legal Business Name): BLUEGRASS MENTAL HEALTH AND MENTAL RETARDATION BOARD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2011
Last Update Date: 12/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

269 E MAIN ST
PARIS KY
40361-2126
US

IV. Provider business mailing address

1351 NEWTOWN PIKE
LEXINGTON KY
40511-1275
US

V. Phone/Fax

Practice location:
  • Phone: 859-987-6127
  • Fax:
Mailing address:
  • Phone: 859-987-6127
  • Fax: 859-473-0498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1288
License Number StateKY

VIII. Authorized Official

Name: SHANNON WARE
Title or Position: CEO
Credential:
Phone: 859-253-1686