=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922696863
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GUSTAVO ALCANTARA OCAMPO LPCA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2021
-----------------------------------------------------
Last Update Date | 12/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 330 HOPE ST
-----------------------------------------------------
City | MT WASHINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40047-7757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-538-1000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1351 NEWTOWN PIKE BLDG 1
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40511-1277
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-253-1686
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 265677
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------