Provider Demographics
NPI:1184208696
Name:SURYA MENTAL WELLNESS LLC
Entity Type:Organization
Organization Name:SURYA MENTAL WELLNESS LLC
Other - Org Name:COLECTIVO SURYA MENTAL WELLNESS
Other - Org Type:Other Name
Authorized Official - Title/Position:BILINGUAL CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:NORMA
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:LPCA, CVE, MED
Authorized Official - Phone:502-519-7979
Mailing Address - Street 1:1939 GOLDSMITH LN STE 260
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40218-3174
Mailing Address - Country:US
Mailing Address - Phone:502-519-7979
Mailing Address - Fax:502-792-7274
Practice Address - Street 1:1939 GOLDSMITH LN STE 260
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-3174
Practice Address - Country:US
Practice Address - Phone:502-519-7979
Practice Address - Fax:502-792-7274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-11
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No171R00000XOther Service ProvidersInterpreterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100756220Medicaid