Provider Demographics
NPI:1558679480
Name:TIME OUT COMMUNITY COUNSELING AND CORRECTIONAL SERVICES, LLC
Entity Type:Organization
Organization Name:TIME OUT COMMUNITY COUNSELING AND CORRECTIONAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER/EDUCATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:FARLEY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:270-237-3463
Mailing Address - Street 1:102 W PUBLIC SQ
Mailing Address - Street 2:
Mailing Address - City:SCOTTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42164-1175
Mailing Address - Country:US
Mailing Address - Phone:270-237-3463
Mailing Address - Fax:270-237-3464
Practice Address - Street 1:1502 PARK CITY GLASGOW RD
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-7209
Practice Address - Country:US
Practice Address - Phone:270-678-3138
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-14
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0531101YA0400X
KY1107277163W00000X, 163WA0400X, 163WC0400X, 163WC1600X
KY810288251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)Group - Single Specialty
No163WC0400XNursing Service ProvidersRegistered NurseCase ManagementGroup - Single Specialty
No163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff DevelopmentGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty