Provider Demographics
NPI:1659381580
Name:CUMBERLAND FAMILY BEHAVIORAL HEALTH, PLLC
Entity Type:Organization
Organization Name:CUMBERLAND FAMILY BEHAVIORAL HEALTH, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAQUEL
Authorized Official - Middle Name:F
Authorized Official - Last Name:VASQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-878-1961
Mailing Address - Street 1:1675 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-2050
Mailing Address - Country:US
Mailing Address - Phone:606-878-1961
Mailing Address - Fax:606-877-1958
Practice Address - Street 1:1675 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-2050
Practice Address - Country:US
Practice Address - Phone:606-878-1961
Practice Address - Fax:606-877-1958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY350162084P0800X, 2084P0804X
KY3220P363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65943177Medicaid
KY65943177Medicaid