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General NPI Number Information
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NPI Number | 1225395023
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Entity Type | Organization
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Legal Business Name | LIVEWISE LLC
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Dates
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Enumeration Date | 04/18/2012
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Last Update Date | 04/18/2012
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Provider Practice Location Address
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Address Line | 103 ENGLEWOOD DR
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City | BARDSTOWN
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State | KY
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Zip | 40004-2520
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Country | US
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Telephone | 502-510-3630
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Fax |
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Provider Business Mailing Address
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Address Line | 103 ENGLEWOOD DR
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City | BARDSTOWN
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State | KY
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Zip | 40004-2520
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Country | US
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Telephone | 502-510-3630
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JAY ANTHONY HALL
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Credential | LCSW
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Telephone | 502-510-3630
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | KY-1412
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License Number State | KY
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