Provider Demographics
NPI:1013315837
Name:SUMMIT MENTAL WELLNESS AND COUNSELING
Entity Type:Organization
Organization Name:SUMMIT MENTAL WELLNESS AND COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:GAIL
Authorized Official - Last Name:WENZ-SHERRILL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:270-748-5638
Mailing Address - Street 1:665 W JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-4259
Mailing Address - Country:US
Mailing Address - Phone:270-748-5638
Mailing Address - Fax:866-824-4022
Practice Address - Street 1:4630 VILLAGE SQUARE DR
Practice Address - Street 2:SUITE 202
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-7502
Practice Address - Country:US
Practice Address - Phone:270-777-4490
Practice Address - Fax:866-824-4022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-10
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0900372251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100277890Medicaid