Basic Information
| Provider Information | |||||||||
| NPI: | 1801933247 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNICARE INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 107 CRANES ROOST CT | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427013650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707652605 | ||||||||
| FaxNumber: | 2702348572 | ||||||||
| Practice Location | |||||||||
| Address1: | 1311 N DIXIE HWY | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427012621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707652605 | ||||||||
| FaxNumber: | 2702348572 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| LastUpdateDate: | 07/25/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WISE | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2707652605 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNICARE INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 800005 | KY | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 000000057131 | 01 | KY | ANTHEM | OTHER | 050651000 | 01 | KY | MAGELLAN | OTHER | 2448575000 | 01 | KY | PASSPORT ADVANTAGE | OTHER | 3060501800 | 05 | KY | MEDICAID |