Provider Demographics
NPI:1619127628
Name:OVERBERG, MARY (MSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:OVERBERG
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 SEMINARY ROAD
Mailing Address - Street 2:
Mailing Address - City:OWENTON
Mailing Address - State:KY
Mailing Address - Zip Code:40359
Mailing Address - Country:US
Mailing Address - Phone:502-484-3464
Mailing Address - Fax:
Practice Address - Street 1:155 SEMINARY ROAD
Practice Address - Street 2:
Practice Address - City:OWENTON
Practice Address - State:KY
Practice Address - Zip Code:40359
Practice Address - Country:US
Practice Address - Phone:502-484-3464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-26
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5417101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY610661458OtherGROUP TAX ID NUMBER