=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265995062
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VANESSA LIN TIRABASSI LPA, LCADC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2019
-----------------------------------------------------
Last Update Date | 02/22/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2141 SPENCER CT
-----------------------------------------------------
City | LA GRANGE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40031-6742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-589-8600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10401 LINN STATION RD STE 100
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40223-3842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-589-8600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 267310
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 245804
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 266181
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 282223
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------