1811231897 NPI number — KIM SEGO TULLY, LCSW, PSYCHOTHERAPY SERVICES

Table of content: (NPI 1811231897)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811231897 NPI number — KIM SEGO TULLY, LCSW, PSYCHOTHERAPY SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIM SEGO TULLY, LCSW, PSYCHOTHERAPY SERVICES
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:
1811231897
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/02/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
589 RUE LA GRANDE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELIZABETHTOWN
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42701-3135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
240 W DIXIE AVE
Provider Second Line Business Practice Location Address:
SUITE 5-B
Provider Business Practice Location Address City Name:
ELIZABETHTOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42701-1586
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-307-3672
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/15/2012

Additional Information

Authorized Official

Authorized Official Last Name:
TULLY
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
SEGO
Authorized Official Title or Position:
SOLE MEMBER
Authorized Official Telephone Number:
270-307-3672

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  3167 , 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)





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