MEDICARE: CONNECTIVE HEALING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1013444918
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONNECTIVE HEALING LLC

Provider Business Mailing Address
First Line	:	319 LAKE NEOMIA RD
Second Line	:
City	:	CLAY CITY
State	:	KY
Zip	:	40312-9701
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 N MAIN ST
Second Line	:
City	:	STANTON
State	:	KY
Zip	:	40380-2174
Country	:	US
Telephone Number	:	859-230-5957
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LISA COFFEY
Credential	:
Telephone Number	:	859-230-5957

Provider Enumeration Date	:	05/23/2017
Last Update Date	:	05/23/2017

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