=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306289293
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GLOW THERAPEUTIC SERVICES OF KENTUCKY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2013
-----------------------------------------------------
Last Update Date | 10/04/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 210 W 3RD ST
-----------------------------------------------------
City | OWENSBORO
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42303-4121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-453-8543
-----------------------------------------------------
Fax | 270-906-1150
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 210 W 3RD ST
-----------------------------------------------------
City | OWENSBORO
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42303-4121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-453-8543
-----------------------------------------------------
Fax | 270-906-1150
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OUTPATIENT THERAPIST
-----------------------------------------------------
Name | MS. MARISSA S HUBERT
-----------------------------------------------------
Credential | LCSW, CADC
-----------------------------------------------------
Telephone | 812-453-8543
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 0981
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 3407
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------