Healthcare Provider Details

I. General information

NPI: 1245498872
Provider Name (Legal Business Name): MINDPSI: SCHOOL PSYCHOLOGICAL SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2008
Last Update Date: 02/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 LEXINGTON RD
RICHMOND KY
40475-1059
US

IV. Provider business mailing address

1421 LEXINGTON RD
RICHMOND KY
40475-1059
US

V. Phone/Fax

Practice location:
  • Phone: 859-358-6791
  • Fax: 859-624-2454
Mailing address:
  • Phone: 859-358-6791
  • Fax: 859-624-2454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DAN W FLORELL
Title or Position: CEO
Credential: PH.D.
Phone: 859-358-6791