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General NPI Number Information
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NPI Number | 1770179517
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Entity Type | Organization
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Legal Business Name | LOUISVILLE PSYCHOTHERAPY GROUP, LLC
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Dates
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Enumeration Date | 12/16/2020
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Last Update Date | 12/16/2020
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Provider Practice Location Address
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Address Line | 1711 BARDSTOWN RD STE 202
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City | LOUISVILLE
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State | KY
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Zip | 40205-2258
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Country | US
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Telephone | 502-208-8794
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Fax |
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Provider Business Mailing Address
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Address Line | 2239 1/2 TALBOTT AVE
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City | LOUISVILLE
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State | KY
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Zip | 40205-2271
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Country | US
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Telephone | 404-290-7916
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ERIC RUSS
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Credential | PH.D.
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Telephone | 404-290-7916
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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