Provider Demographics
NPI:1619127636
Name:ROUHOLIMAN, MARY (MFTA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ROUHOLIMAN
Suffix:
Gender:F
Credentials:MFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1714 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:KY
Mailing Address - Zip Code:41008
Mailing Address - Country:US
Mailing Address - Phone:502-732-9331
Mailing Address - Fax:
Practice Address - Street 1:1714 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:KY
Practice Address - Zip Code:41008
Practice Address - Country:US
Practice Address - Phone:502-732-9331
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
KYKY-08-017101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY610661458OtherGROUP TAX ID