Provider Demographics
NPI:1083816888
Name:NORTHERN KENTUCKY MENTAL HEALTH MENTAL RETARDATION REGIONAL BOARD
Entity Type:Organization
Organization Name:NORTHERN KENTUCKY MENTAL HEALTH MENTAL RETARDATION REGIONAL BOARD
Other - Org Name:NORTHKEY COMMUNITY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:OWEN
Authorized Official - Middle Name:T
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:859-578-3252
Mailing Address - Street 1:503 FARRELL DRIVE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011
Mailing Address - Country:US
Mailing Address - Phone:859-578-3200
Mailing Address - Fax:859-578-3273
Practice Address - Street 1:503 FARRELL DRIVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41011
Practice Address - Country:US
Practice Address - Phone:859-578-3200
Practice Address - Fax:859-578-3273
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHERN KENTUCKY MENTAL HEALTH MENTAL RETARDATION REGIONAL BOARD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-04
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY800084261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY33900275Medicaid