Provider Demographics
NPI:1578680344
Name:GATLIN, DANIEL G (PHD, CADC)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:G
Last Name:GATLIN
Suffix:
Gender:M
Credentials:PHD, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W MUHAMMAD ALI BLVD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1423
Mailing Address - Country:US
Mailing Address - Phone:502-589-8600
Mailing Address - Fax:
Practice Address - Street 1:130 S JOE B HALL AVE
Practice Address - Street 2:
Practice Address - City:SHEPHERDSVILLE
Practice Address - State:KY
Practice Address - Zip Code:40165-6009
Practice Address - Country:US
Practice Address - Phone:502-955-6447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-24
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1042103T00000X
KYKY-1042103TA0400X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP300014754OtherMEDICARE PTAN