Provider Demographics
NPI:1912540105
Name:KURTZ, THOMAS C (LCSW)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:C
Last Name:KURTZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 NORTH DIXIE SUITE B100
Mailing Address - Street 2:B100 SUITE
Mailing Address - City:ELIZABTHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701
Mailing Address - Country:US
Mailing Address - Phone:270-900-0576
Mailing Address - Fax:
Practice Address - Street 1:599 ROGERSVILLE RD
Practice Address - Street 2:
Practice Address - City:RADCLIFF
Practice Address - State:KY
Practice Address - Zip Code:40160-9321
Practice Address - Country:US
Practice Address - Phone:502-262-2887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-21
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKYCSW2533691041C0700X
KY2552941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100648780Medicaid