Provider Demographics
NPI:1922108471
Name:BRACKETT, GEORGETTE MARIE (LIC MARRIAGE & FAMIL)
Entity Type:Individual
Prefix:MRS
First Name:GEORGETTE
Middle Name:MARIE
Last Name:BRACKETT
Suffix:
Gender:F
Credentials:LIC MARRIAGE & FAMIL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 B BROWNS LANE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207
Mailing Address - Country:US
Mailing Address - Phone:502-721-7522
Mailing Address - Fax:502-721-7556
Practice Address - Street 1:1400 B BROWNS LANE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207
Practice Address - Country:US
Practice Address - Phone:502-721-7522
Practice Address - Fax:502-721-7556
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0010106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist