Provider Demographics
NPI: | 1932467867 |
---|---|
Name: | THERAPEUTIC INTERVENTION SERVICES |
Entity Type: | Organization |
Organization Name: | THERAPEUTIC INTERVENTION SERVICES |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | MEMBER |
Authorized Official - Prefix: | MS |
Authorized Official - First Name: | LILI |
Authorized Official - Middle Name: | S |
Authorized Official - Last Name: | LUTGENS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | LCSW |
Authorized Official - Phone: | 502-762-6258 |
Mailing Address - Street 1: | 4303 EMERALD WAY |
Mailing Address - Street 2: | |
Mailing Address - City: | NEW ALBANY |
Mailing Address - State: | IN |
Mailing Address - Zip Code: | 47150-9330 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 2210 GOLDSMITH LN |
Practice Address - Street 2: | SUITE 100 |
Practice Address - City: | LOUISVILLE |
Practice Address - State: | KY |
Practice Address - Zip Code: | 40218-1038 |
Practice Address - Country: | US |
Practice Address - Phone: | 502-762-6258 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2012-04-28 |
Last Update Date: | 2015-02-24 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
KY | 7100225100 | 101YM0800X, 103K00000X, 103TC0700X, 103TM1800X, 1041C0700X, 106H00000X, 225100000X, 225X00000X, 235Z00000X |
133N00000X, 133V00000X, 251S00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 251S00000X | Agencies | Community/Behavioral Health | ||
No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health | Group - Multi-Specialty |
No | 103K00000X | Behavioral Health & Social Service Providers | Behavior Analyst | Group - Multi-Specialty | |
No | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical | Group - Multi-Specialty |
No | 103TM1800X | Behavioral Health & Social Service Providers | Psychologist | Intellectual & Developmental Disabilities | Group - Multi-Specialty |
No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
No | 106H00000X | Behavioral Health & Social Service Providers | Marriage & Family Therapist | Group - Multi-Specialty | |
No | 133N00000X | Dietary & Nutritional Service Providers | Nutritionist | Group - Multi-Specialty | |
No | 133V00000X | Dietary & Nutritional Service Providers | Dietitian, Registered | Group - Multi-Specialty | |
No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty | |
No | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Group - Multi-Specialty | |
No | 235Z00000X | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
KY | 7100225100 | Medicaid | |
7100318540 | Other | EPSDT |