Provider Demographics
NPI:1235774522
Name:HARBOR OF HOPE MEDICAL AND BEHAVIORAL HEALTH CARE, LLC
Entity Type:Organization
Organization Name:HARBOR OF HOPE MEDICAL AND BEHAVIORAL HEALTH CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:THELMA
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:606-269-3428
Mailing Address - Street 1:868 SAM PARKER RD
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:KY
Mailing Address - Zip Code:40734-6780
Mailing Address - Country:US
Mailing Address - Phone:606-269-3428
Mailing Address - Fax:
Practice Address - Street 1:185 TREUHAFT BLVD APT 4
Practice Address - Street 2:
Practice Address - City:BARBOURVILLE
Practice Address - State:KY
Practice Address - Zip Code:40906-8300
Practice Address - Country:US
Practice Address - Phone:606-545-6766
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HARBOR OF HOPE MEDICAL AND BEHAVIORAL HEALTH CARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-11-11
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100615630Medicaid