Healthcare Provider Details

I. General information

NPI: 1134513252
Provider Name (Legal Business Name): MILES OF HOPE COUNSELING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2015
Last Update Date: 03/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 N 2ND ST
STANFORD KY
40484-1321
US

IV. Provider business mailing address

107 N 2ND ST
STANFORD KY
40484-1321
US

V. Phone/Fax

Practice location:
  • Phone: 606-303-3560
  • Fax: 606-365-2263
Mailing address:
  • Phone: 606-303-3560
  • Fax: 606-365-2263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number4004
License Number StateKY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: CARLA LOVELESS-TACKETT
Title or Position: OWNER/CLINICAL SOCIAL WORKER
Credential: MSW, LCSW, ACSW
Phone: 606-303-3560