Provider Demographics
NPI:1598298770
Name:TULLY, ELIZABETH (MSSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:
Last Name:TULLY
Suffix:
Gender:F
Credentials:MSSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10101 LINN STATION RD STE 600
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-3818
Mailing Address - Country:US
Mailing Address - Phone:502-589-8600
Mailing Address - Fax:
Practice Address - Street 1:4710 CHAMPIONS TRACE LN STE 107
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218
Practice Address - Country:US
Practice Address - Phone:502-454-6343
Practice Address - Fax:502-459-9209
Is Sole Proprietor?:No
Enumeration Date:2017-04-05
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6539104100000X
KY2535851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1083722367Medicaid