1013315837 NPI number — SUMMIT MENTAL WELLNESS AND COUNSELING

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013315837 NPI number — SUMMIT MENTAL WELLNESS AND COUNSELING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUMMIT MENTAL WELLNESS AND COUNSELING
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013315837
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/11/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
665 W JEFFERSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PADUCAH
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42001-4259
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-748-5638
Provider Business Mailing Address Fax Number:
866-824-4022

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4630 VILLAGE SQUARE DR
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
PADUCAH
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42001-7502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-777-4490
Provider Business Practice Location Address Fax Number:
866-824-4022
Provider Enumeration Date:
12/10/2014

Additional Information

Authorized Official

Authorized Official Last Name:
WENZ-SHERRILL
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
GAIL
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
270-748-5638

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  0900372 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7100277890 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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