Provider Demographics
NPI:1447619598
Name:LAKE CUMBERLAND REG MHMR BOARD CDO
Entity Type:Organization
Organization Name:LAKE CUMBERLAND REG MHMR BOARD CDO
Other - Org Name:THE ADANTA GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT TO THE CEO
Authorized Official - Prefix:
Authorized Official - First Name:TRACIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HORTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-679-4782
Mailing Address - Street 1:130 SOUTHERN SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42501-3223
Mailing Address - Country:US
Mailing Address - Phone:606-679-4782
Mailing Address - Fax:
Practice Address - Street 1:130 SOUTHERN SCHOOL RD
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501-3223
Practice Address - Country:US
Practice Address - Phone:606-679-4782
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-17
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY800019251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health