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General NPI Number Information
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NPI Number | 1205534062
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Entity Type | Organization
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Legal Business Name | TRANSFORMATIVE JUSTICE MENTAL HEALTH CLINIC
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Dates
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Enumeration Date | 02/21/2023
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Last Update Date | 02/21/2023
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Provider Practice Location Address
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Address Line | 225 N CLIFTON AVE STE 6
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City | LOUISVILLE
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State | KY
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Zip | 40206-2438
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Country | US
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Telephone | 502-496-4928
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Fax |
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Provider Business Mailing Address
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Address Line | 225 N CLIFTON AVE STE 6
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City | LOUISVILLE
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State | KY
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Zip | 40206-2438
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. IDA DICKIE
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Credential |
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Telephone | 502-457-4750
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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