=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861891541
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHEPHERD'S HOUSE INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2014
-----------------------------------------------------
Last Update Date | 03/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 635 MAXWELTON CT
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40508-4012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-252-1939
-----------------------------------------------------
Fax | 859-252-1935
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 635 MAXWELTON CT
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40508-4012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-252-1939
-----------------------------------------------------
Fax | 859-252-1935
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR OF MENTAL HEALTH
-----------------------------------------------------
Name | KYLE RICHARD NOWKA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 502-303-2980
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | 810066
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------