Provider Demographics
NPI:1285043844
Name:GREATER LOUISVILLE COUNSELING CENTER
Entity Type:Organization
Organization Name:GREATER LOUISVILLE COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKENZIE
Authorized Official - Suffix:
Authorized Official - Credentials:CADC
Authorized Official - Phone:502-587-9737
Mailing Address - Street 1:332 W BROADWAY STE 905
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-2133
Mailing Address - Country:US
Mailing Address - Phone:502-587-9737
Mailing Address - Fax:
Practice Address - Street 1:332 W BROADWAY STE 905
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-2133
Practice Address - Country:US
Practice Address - Phone:502-587-9737
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-07
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY810005251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100323580Medicaid