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General NPI Number Information
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NPI Number | 1033005079
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Entity Type | Organization
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Legal Business Name | MINDCLUB KENTUCKY LLC
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Dates
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Enumeration Date | 06/16/2025
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Last Update Date | 06/16/2025
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Provider Practice Location Address
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Address Line | 111 DERRICK PL
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City | HOPKINSVILLE
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State | KY
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Zip | 42240-1325
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Country | US
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Telephone | 833-833-9655
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Fax |
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Provider Business Mailing Address
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Address Line | 106 MISSION CT STE 201A
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City | FRANKLIN
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State | TN
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Zip | 37067-6441
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Country | US
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Telephone | 153-902-8656
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Fax |
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Authorized Official
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Title or Position | VP, CAO
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Name | KATHY RICHARDSON
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Credential |
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Telephone | 615-390-2865
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number |
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License Number State |
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