Provider Demographics
NPI:1518369040
Name:HERITAGE COUNSELING AND CONSULTATION CENTER, LLC
Entity Type:Organization
Organization Name:HERITAGE COUNSELING AND CONSULTATION CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:GERALDINE
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:270-996-5877
Mailing Address - Street 1:611 PEACEFUL DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-6465
Mailing Address - Country:US
Mailing Address - Phone:270-996-5877
Mailing Address - Fax:
Practice Address - Street 1:611 PEACEFUL DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-6465
Practice Address - Country:US
Practice Address - Phone:270-996-5877
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-16
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY=========OtherEIN