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General NPI Number Information
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NPI Number | 1548035223
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Entity Type | Organization
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Legal Business Name | HOME AWAY FROM HOME THERAPEUTIC CENTER
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Dates
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Enumeration Date | 11/22/2023
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Last Update Date | 11/22/2023
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Provider Practice Location Address
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Address Line | 849 S 37TH ST
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City | LOUISVILLE
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State | KY
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Zip | 40211-2811
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Country | US
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Telephone | 502-618-9204
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Fax |
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Provider Business Mailing Address
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Address Line | 1828 BOLLING AVE
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City | LOUISVILLE
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State | KY
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Zip | 40210-1908
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Country | US
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Telephone | 502-618-9205
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Fax |
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Authorized Official
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Title or Position | OWENER/OPERATOR
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Name | SHAQUILA COOPER
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Credential | DSW, LCSW
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Telephone | 502-618-9205
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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 |
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License Number State |
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