Basic Information
| Provider Information | |||||||||
| NPI: | 1578680344 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GATLIN | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | G. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PH.D., CADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 W MUHAMMAD ALI BLVD | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025898600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 130 S JOE B HALL AVE | ||||||||
| Address2: | |||||||||
| City: | SHEPHERDSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 401656009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5029556447 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2007 | ||||||||
| LastUpdateDate: | 07/29/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 1042 | KY | Y | Behavioral Health & Social Service Providers | Psychologist | 103TA0400X | KY-1042 | KY | N | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) | 103TC0700X | KY-1042 | KY | N | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | P300014754 | 01 | KY | MEDICARE PTAN | OTHER |