Provider Demographics
NPI:1467851667
Name:ML CANTRELL PSYCHOTHERAPEUTIC SERVICES, PLLC
Entity Type:Organization
Organization Name:ML CANTRELL PSYCHOTHERAPEUTIC SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LOU
Authorized Official - Last Name:CANTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPP
Authorized Official - Phone:606-743-2407
Mailing Address - Street 1:849 HIGHWAY 191
Mailing Address - Street 2:
Mailing Address - City:WEST LIBERTY
Mailing Address - State:KY
Mailing Address - Zip Code:41472-8315
Mailing Address - Country:US
Mailing Address - Phone:606-743-2407
Mailing Address - Fax:
Practice Address - Street 1:1219 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST LIBERTY
Practice Address - State:KY
Practice Address - Zip Code:41472-2161
Practice Address - Country:US
Practice Address - Phone:606-743-2407
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPSYPPR00193411103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty