Provider Demographics
NPI:1760264675
Name:FULL CIRCLE INTEGRATIVE HEALING
Entity Type:Organization
Organization Name:FULL CIRCLE INTEGRATIVE HEALING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:CLEMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:502-291-4094
Mailing Address - Street 1:3917 HYCLIFFE AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-3838
Mailing Address - Country:US
Mailing Address - Phone:502-291-4094
Mailing Address - Fax:502-237-9072
Practice Address - Street 1:214 BRECKENRIDGE LN STE 203
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-3879
Practice Address - Country:US
Practice Address - Phone:502-200-9836
Practice Address - Fax:502-237-9072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100323780Medicaid
KY7100855840Medicaid