=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639875693
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HARBOR OF HOPE MEDICAL AND BEHAVIORAL HEALTH CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2023
-----------------------------------------------------
Last Update Date | 02/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 185 TREUHAFT BLVD SUITE 4
-----------------------------------------------------
City | BARBOURVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-546-6766
-----------------------------------------------------
Fax | 606-545-0366
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 185 TREUHAFT BLVD SUITE 4
-----------------------------------------------------
City | BARBOURVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-546-6766
-----------------------------------------------------
Fax | 606-545-0366
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | APRN/OWNER
-----------------------------------------------------
Name | THELMA JEAN GRAY
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 606-545-6766
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------