=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861924953
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE SPRINGS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2017
-----------------------------------------------------
Last Update Date | 03/29/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 138 KENT HAVEN DR
-----------------------------------------------------
City | SOMERSET
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42503-6281
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-676-2513
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 138 KENT HAVEN DR
-----------------------------------------------------
City | SOMERSET
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42503-6281
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | MR. DUSTIN E PHELPS
-----------------------------------------------------
Credential | MS
-----------------------------------------------------
Telephone | 606-676-2513
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | KY-0085
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------