Basic Information
| Provider Information | |||||||||
| NPI: | 1184385841 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THRIVEWORKS KENTUCKY - CLINICAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THRIVEWORKS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 JEFFERSON ST STE 2C | ||||||||
| Address2: | |||||||||
| City: | LYNCHBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245041724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402176461 | ||||||||
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| Practice Location | |||||||||
| Address1: | 310 E MAIN AVE STE 202 | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421012143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552847483 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2022 | ||||||||
| LastUpdateDate: | 07/11/2022 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | NATHAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING AGENT | ||||||||
| AuthorizedOfficialTelephone: | 5402176461 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.