Provider Demographics
NPI:1922696863
Name:ALCANTARA OCAMPO, GUSTAVO (LPCA)
Entity Type:Individual
Prefix:MR
First Name:GUSTAVO
Middle Name:
Last Name:ALCANTARA OCAMPO
Suffix:
Gender:M
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1351 NEWTOWN PIKE BLDG 1
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40511-1277
Mailing Address - Country:US
Mailing Address - Phone:859-253-1686
Mailing Address - Fax:
Practice Address - Street 1:330 HOPE ST
Practice Address - Street 2:
Practice Address - City:MT WASHINGTON
Practice Address - State:KY
Practice Address - Zip Code:40047-7757
Practice Address - Country:US
Practice Address - Phone:502-538-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-06
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY265677101YM0800X
KY101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid