Healthcare Provider Details

I. General information

NPI: 1659719086
Provider Name (Legal Business Name): MISTY DAWN MURRAY TLBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2013
Last Update Date: 09/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 SECOND ST
SOMERSET KY
42501-2390
US

IV. Provider business mailing address

282 HAZELWOOD RD
ANNVILLE KY
40402-9075
US

V. Phone/Fax

Practice location:
  • Phone: 606-677-1166
  • Fax:
Mailing address:
  • Phone: 606-364-2126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number244267
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number201136144
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: