Provider Demographics
NPI:1942935341
Name:HOUSE OF DEMI MENTAL HEALTH AND WELLNESS
Entity Type:Organization
Organization Name:HOUSE OF DEMI MENTAL HEALTH AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEMETRIA
Authorized Official - Middle Name:TYRAU
Authorized Official - Last Name:JANUARY
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC-NCC
Authorized Official - Phone:502-641-1877
Mailing Address - Street 1:12123 SHELBYVILLE RD STE 100413
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40243-1079
Mailing Address - Country:US
Mailing Address - Phone:502-641-1877
Mailing Address - Fax:
Practice Address - Street 1:904 MARLOWS FORD RD APT 201
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40245-4779
Practice Address - Country:US
Practice Address - Phone:502-641-1877
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-19
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health