Basic Information
| Provider Information | |||||||||
| NPI: | 1083902191 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KVC BEHAVIORAL HEALTHCARE KENTUCKY INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2250 THUNDERSTICK DR STE 1104 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405059009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592541035 | ||||||||
| FaxNumber: | 8592542075 | ||||||||
| Practice Location | |||||||||
| Address1: | 2250 THUNDERSTICK DR STE 1104 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405059009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592541035 | ||||||||
| FaxNumber: | 8592542075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2011 | ||||||||
| LastUpdateDate: | 05/21/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KLYACHKIN | ||||||||
| AuthorizedOfficialFirstName: | REGINA | ||||||||
| AuthorizedOfficialMiddleName: | MARIA | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9133224900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KVC HEALTH SYSTEMS INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 302R00000X | KY | N | Managed Care Organizations | Health Maintenance Organization | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 7100283480 | 05 | KY | MEDICAID | 7100284110 | 05 | KY | MEDICAID | 7100318330 | 05 | KY | MEDICAID |