=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922601376
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMAZING LIFE-KY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2020
-----------------------------------------------------
Last Update Date | 02/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 351 PASCOE BLVD STE 102
-----------------------------------------------------
City | BOWLING GREEN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42104-6302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-904-4945
-----------------------------------------------------
Fax | 270-721-0988
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 351 PASCOE BLVD STE 102
-----------------------------------------------------
City | BOWLING GREEN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42104-6302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-904-4945
-----------------------------------------------------
Fax | 270-721-0988
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CATHERINE GAMM
-----------------------------------------------------
Credential | MA, LPCC-S
-----------------------------------------------------
Telephone | 989-708-0479
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------