Provider Demographics
NPI:1659881282
Name:KENTUCKIANA BEHAVIOR THERAPY PLLC
Entity Type:Organization
Organization Name:KENTUCKIANA BEHAVIOR THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIOR ANALYST
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:O'BRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-554-1900
Mailing Address - Street 1:5502 CHARLESTOWN PIKE
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-8755
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5502 CHARLESTOWN PIKE
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-8755
Practice Address - Country:US
Practice Address - Phone:502-554-1900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-10
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1-16-21910103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty