=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679355697
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ESTILL BEHAVIORAL HEALTH, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2023
-----------------------------------------------------
Last Update Date | 10/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 721 RIVER DR
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40336-1255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-749-8768
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 721 RIVER DR
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40336-1255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | APRN, PMHNP-BC
-----------------------------------------------------
Name | MELISSA YOUNG-FLYNN
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 859-749-8768
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------