Provider Demographics
NPI:1245767938
Name:INTEGRATIVE PSYCHOLOGY & COUNSELING SPECIALISTS
Entity Type:Organization
Organization Name:INTEGRATIVE PSYCHOLOGY & COUNSELING SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, LICESNED PSYCHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:ABRIELLE
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:CONWAY
Authorized Official - Suffix:
Authorized Official - Credentials:PSC
Authorized Official - Phone:270-215-2373
Mailing Address - Street 1:102 WINSTON WAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-1593
Mailing Address - Country:US
Mailing Address - Phone:270-215-2373
Mailing Address - Fax:888-975-1981
Practice Address - Street 1:102 WINSTON WAY
Practice Address - Street 2:SUITE A
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-1593
Practice Address - Country:US
Practice Address - Phone:270-215-2373
Practice Address - Fax:888-975-1981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-12
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY106483101YM0800X
KY130473103TC0700X
KYKY17711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100323430Medicaid
KY130473OtherMEDICAL LICENSE