=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306304985
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARSHALL STEVENS LPCC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2019
-----------------------------------------------------
Last Update Date | 12/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 130 CLARK ST
-----------------------------------------------------
City | FLEMINGSBURG
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41041-1207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-209-0036
-----------------------------------------------------
Fax | 606-209-0149
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 89 2ND ST
-----------------------------------------------------
City | FLEMINGSBURG
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41041-8069
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-291-8830
-----------------------------------------------------
Fax | 606-209-0149
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 283599
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------