Provider Demographics
NPI:1710533773
Name:THERAPEUTIC ALLIANCE OF LOUISVILLE LLC
Entity Type:Organization
Organization Name:THERAPEUTIC ALLIANCE OF LOUISVILLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-655-8105
Mailing Address - Street 1:11110 SEWELL DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40291-4124
Mailing Address - Country:US
Mailing Address - Phone:502-655-8105
Mailing Address - Fax:
Practice Address - Street 1:11110 SEWELL DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40291-4124
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty