Provider Demographics
NPI:1629123443
Name:THERAPEUTIC COLLABORATIVE
Entity Type:Organization
Organization Name:THERAPEUTIC COLLABORATIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MS
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:PEPPERS
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP BC
Authorized Official - Phone:859-572-0400
Mailing Address - Street 1:519 LICKING PIKE
Mailing Address - Street 2:
Mailing Address - City:WILDER
Mailing Address - State:KY
Mailing Address - Zip Code:41071
Mailing Address - Country:US
Mailing Address - Phone:859-572-0400
Mailing Address - Fax:859-442-3363
Practice Address - Street 1:519 LICKING PIKE
Practice Address - Street 2:
Practice Address - City:WILDER
Practice Address - State:KY
Practice Address - Zip Code:41071
Practice Address - Country:US
Practice Address - Phone:859-572-0400
Practice Address - Fax:859-442-3363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & AdolescentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65928897Medicaid
KY0385301Medicare ID - Type Unspecified