=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790372969
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BINGHAM BEHAVIORAL HEALTH CARE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/22/2020
-----------------------------------------------------
Last Update Date | 01/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 417 KNOX ST STE 3
-----------------------------------------------------
City | BARBOURVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40906-1342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-545-9752
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 417 KNOX ST STE 3
-----------------------------------------------------
City | BARBOURVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40906-1342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-545-9752
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | VIVIAN BINGHAM
-----------------------------------------------------
Credential | LCADC
-----------------------------------------------------
Telephone | 859-545-9752
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------