Healthcare Provider Details

I. General information

NPI: 1306324504
Provider Name (Legal Business Name): LEANN NICOLE MATHENY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2018
Last Update Date: 07/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

363 W LINCOLN TRAIL BLVD
RADCLIFF KY
40160
US

IV. Provider business mailing address

464 SPRINGFIELD RD APT 2A
ELIZABETHTOWN KY
42701-6864
US

V. Phone/Fax

Practice location:
  • Phone: 270-352-1133
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-18-61984
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: