Healthcare Provider Details

I. General information

NPI: 1952445017
Provider Name (Legal Business Name): THERAPEUTIC COLLABORTIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 LICKING PIKE
WILDER KY
41071
US

IV. Provider business mailing address

525 LICKING PIKE
ALEXANDRIA KY
41071
US

V. Phone/Fax

Practice location:
  • Phone: 859-572-0400
  • Fax: 859-442-3363
Mailing address:
  • Phone: 859-572-0400
  • Fax: 859-442-3363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1309
License Number StateKY

VIII. Authorized Official

Name: MRS. RUTH MARGARET LUKEY
Title or Position: LCSW
Credential: LCSW
Phone: 859-572-0400