1942935341 NPI number — HOUSE OF DEMI MENTAL HEALTH AND WELLNESS

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 1942935341 NPI number — HOUSE OF DEMI MENTAL HEALTH AND WELLNESS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOUSE OF DEMI MENTAL HEALTH AND WELLNESS
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:
1942935341
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12123 SHELBYVILLE RD STE 100413
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40243-1079
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-641-1877
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
904 MARLOWS FORD RD APT 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40245-4779
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-641-1877
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/19/2022

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JANUARY
Authorized Official First Name:
DEMETRIA
Authorized Official Middle Name:
TYRAU
Authorized Official Title or Position:
OWNER / CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
502-641-1877

Provider Taxonomy Codes

  • Taxonomy code: 261QM0850X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0855X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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