=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558186411
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GERALD'S WAY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2024
-----------------------------------------------------
Last Update Date | 11/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4805 COFER AVE
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40258-1337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-631-7621
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4805 COFER AVE
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40258-1337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-631-7621
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BOARD MEMBER
-----------------------------------------------------
Name | BRENT STAHR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 502-631-7621
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------