Provider Demographics
NPI:1275684698
Name:SPECTRA MENTAL HEALTHCARE, PLLC
Entity Type:Organization
Organization Name:SPECTRA MENTAL HEALTHCARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KARL
Authorized Official - Middle Name:
Authorized Official - Last Name:BATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-893-3388
Mailing Address - Street 1:214 BRECKENRIDGE LN
Mailing Address - Street 2:104
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-3868
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:214 BRECKENRIDGE LN
Practice Address - Street 2:104
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-3868
Practice Address - Country:US
Practice Address - Phone:502-893-3388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-13
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000344330OtherANTHEM BLUE CROSS & BLUE SHIELD
KY8290021800Medicaid
KY9365Medicare ID - Type Unspecified