Provider Demographics
NPI:1790714301
Name:RALSTON, DAVID J (PHD, LCCC, ATC)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:J
Last Name:RALSTON
Suffix:
Gender:M
Credentials:PHD, LCCC, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 W 10TH ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-2900
Mailing Address - Country:US
Mailing Address - Phone:270-316-6960
Mailing Address - Fax:
Practice Address - Street 1:319 W 10TH ST
Practice Address - Street 2:SUITE 102
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-2900
Practice Address - Country:US
Practice Address - Phone:270-316-6960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY00742255A2300X
KY15038101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY00074OtherNATIONAL ATHLETIC TRAINERS ASSOCIATION
15038OtherNATIONAL CHRISTIAN COUNSELORS ASSOCIATION