Provider Demographics
NPI:1851435705
Name:BELLEWOOD PRESBYTERIAN HOME FOR CHILDREN
Entity Type:Organization
Organization Name:BELLEWOOD PRESBYTERIAN HOME FOR CHILDREN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:CANTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:502-245-4171
Mailing Address - Street 1:PO BOX 23309
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-0309
Mailing Address - Country:US
Mailing Address - Phone:502-245-4171
Mailing Address - Fax:502-245-7447
Practice Address - Street 1:11103 PARK RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-2424
Practice Address - Country:US
Practice Address - Phone:502-245-4171
Practice Address - Fax:502-245-7447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY29900016Medicaid
KY65936098Medicaid