Provider Demographics
NPI:1285823971
Name:OWENSBORO BEHAVIORAL CARE PSC
Entity Type:Organization
Organization Name:OWENSBORO BEHAVIORAL CARE PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OLUWOLE
Authorized Official - Middle Name:O
Authorized Official - Last Name:OLUSOLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-971-8222
Mailing Address - Street 1:920 FREDERICA ST STE 407
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-3079
Mailing Address - Country:US
Mailing Address - Phone:270-316-9616
Mailing Address - Fax:812-359-4481
Practice Address - Street 1:920 FREDERICA ST STE 407
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-3079
Practice Address - Country:US
Practice Address - Phone:270-316-9616
Practice Address - Fax:812-359-4481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY01045882A101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000051385OtherBC/BS PIN KY
KY64306046Medicaid
KY000000051385OtherBC/BS PIN KY
KYF84739Medicare UPIN