=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801823828
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUEGRASS REGIONAL PSYCHIATRIC SERVICES INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 627 W FOURTH ST
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40508-1294
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-246-7363
-----------------------------------------------------
Fax | 859-246-7023
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 627 W FOURTH ST
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40508-1294
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-246-7363
-----------------------------------------------------
Fax | 859-246-7023
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FISCAL OFFICE MANAGER
-----------------------------------------------------
Name | MRS. ERICA L ODUSANYA
-----------------------------------------------------
Credential | M.H.A
-----------------------------------------------------
Telephone | 859-246-7363
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 283Q00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Hospital
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------