MEDICARE: DENNIS BROOKS PARK TCADC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	172662	KY

General Provider Information

NPI Number	:	1255816310
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENNIS BROOKS PARK TCADC

Provider Business Mailing Address
First Line	:	2705 OLIVET CHURCH RD
Second Line	:
City	:	PADUCAH
State	:	KY
Zip	:	42001-9755
Country	:	US
Telephone Number	:	270-443-0096
Fax Number	:	270-443-0080

Provider Business Practice Location Address
First Line	:	2705 OLIVET CHURCH RD
Second Line	:
City	:	PADUCAH
State	:	KY
Zip	:	42001-9755
Country	:	US
Telephone Number	:	270-443-0096
Fax Number	:	270-443-0080

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2018
Last Update Date	:	09/25/2018

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