=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134738412
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HARBOR OF HOPE MEDICAL AND BEHAVIORAL HEALTH CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2020
-----------------------------------------------------
Last Update Date | 01/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 185 TREUHAFT BLVD STE 4
-----------------------------------------------------
City | BARBOURVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40906-8300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-545-6766
-----------------------------------------------------
Fax | 606-545-0366
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 868 SAM PARKER RD
-----------------------------------------------------
City | GRAY
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40734-6780
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-269-3428
-----------------------------------------------------
Fax | 606-545-0366
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | APRN/OWNER
-----------------------------------------------------
Name | THELMA JEAN GRAY
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 606-545-6766
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------