=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528640356
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN FAMILY HEALTH & PSYCHIATRY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2021
-----------------------------------------------------
Last Update Date | 09/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1622 CUMBERLAND AVE STE 6
-----------------------------------------------------
City | MIDDLESBORO
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40965-1379
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-268-2504
-----------------------------------------------------
Fax | 606-212-0107
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1839
-----------------------------------------------------
City | BARBOURVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40906-5839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-268-2504
-----------------------------------------------------
Fax | 606-212-0107
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO, OWNER, PROVIDER
-----------------------------------------------------
Name | STEPHANIE DANIELLE GOINS
-----------------------------------------------------
Credential | APRN, PMHNP-BC,FNP-C
-----------------------------------------------------
Telephone | 606-268-2504
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------