Provider Demographics
NPI:1811231897
Name:KIM SEGO TULLY, LCSW, PSYCHOTHERAPY SERVICES
Entity Type:Organization
Organization Name:KIM SEGO TULLY, LCSW, PSYCHOTHERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:SEGO
Authorized Official - Last Name:TULLY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:270-307-3672
Mailing Address - Street 1:589 RUE LA GRANDE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-3135
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:240 W DIXIE AVE
Practice Address - Street 2:SUITE 5-B
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-1586
Practice Address - Country:US
Practice Address - Phone:270-307-3672
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK047852Medicare PIN