Provider Demographics
NPI:1215192109
Name:SILLERY, JAMES (LCSW)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:SILLERY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40212-1033
Mailing Address - Country:US
Mailing Address - Phone:502-774-8631
Mailing Address - Fax:502-772-8189
Practice Address - Street 1:2215 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40212-1033
Practice Address - Country:US
Practice Address - Phone:502-774-8631
Practice Address - Fax:502-772-8189
Is Sole Proprietor?:No
Enumeration Date:2008-07-21
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100303460Medicaid
KYK025712Medicare PIN
KYK025714Medicare PIN
KYK025715Medicare PIN
KY7100303460Medicaid
KYK025713Medicare PIN
KYK025717Medicare PIN
KYK025711Medicare PIN