Basic Information
| Provider Information | |||||||||
| NPI: | 1194163055 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MULLINS | ||||||||
| FirstName: | ALICIA | ||||||||
| MiddleName: | KAY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1080 | ||||||||
| Address2: | |||||||||
| City: | BURKESVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427171080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708586655 | ||||||||
| FaxNumber: | 2708584607 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 LINCOLN PARK ROAD | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400691501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8444350900 | ||||||||
| FaxNumber: | 2708584029 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2013 | ||||||||
| LastUpdateDate: | 09/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | AR | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 7172-C | AR | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 254211 | KY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 7100606470 | 05 | KY | MEDICAID |