Provider Demographics
NPI:1033684477
Name:BIRCHWOOD HEALING PLACE
Entity Type:Organization
Organization Name:BIRCHWOOD HEALING PLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORK / OWN
Authorized Official - Prefix:
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:GILMORE
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:859-312-6569
Mailing Address - Street 1:3101 CLAYS MILL RD STE 204
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-2781
Mailing Address - Country:US
Mailing Address - Phone:859-312-6569
Mailing Address - Fax:855-594-5062
Practice Address - Street 1:3101 CLAYS MILL RD STE 204
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-2781
Practice Address - Country:US
Practice Address - Phone:859-312-6569
Practice Address - Fax:855-594-5062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-12
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100422750Medicaid