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General NPI Number Information
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NPI Number | 1811231897
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Entity Type | Organization
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Legal Business Name | KIM SEGO TULLY, LCSW, PSYCHOTHERAPY SERVICES
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Dates
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Enumeration Date | 11/15/2012
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Last Update Date | 05/02/2017
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Provider Practice Location Address
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Address Line | 240 W DIXIE AVE SUITE 5-B
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City | ELIZABETHTOWN
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State | KY
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Zip | 42701-1586
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Country | US
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Telephone | 270-307-3672
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Fax |
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Provider Business Mailing Address
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Address Line | 589 RUE LA GRANDE
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City | ELIZABETHTOWN
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State | KY
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Zip | 42701-3135
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | KIMBERLY SEGO TULLY
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Credential | LCSW
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Telephone | 270-307-3672
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 3167
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License Number State | KY
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