=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104517358
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EAST KENTUCKY PSYCHIATRIC CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2023
-----------------------------------------------------
Last Update Date | 05/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 72 ALLEN LN
-----------------------------------------------------
City | CAMPTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41301-7899
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-225-2920
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 100
-----------------------------------------------------
City | CAMPTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41301-0100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-225-2920
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHIATRIC NURSE PRACTITIONER
-----------------------------------------------------
Name | MRS. KRISTIAN RENEE ALLEN
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 606-359-1440
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------