Provider Demographics
NPI:1134738412
Name:HARBOR OF HOPE MEDICAL AND BEHAVIORAL HEALTH CARE, LLC
Entity type:Organization
Organization Name:HARBOR OF HOPE MEDICAL AND BEHAVIORAL HEALTH CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APRN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THELMA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:606-545-6766
Mailing Address - Street 1:868 SAM PARKER RD
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:KY
Mailing Address - Zip Code:40734-6780
Mailing Address - Country:US
Mailing Address - Phone:606-269-3428
Mailing Address - Fax:606-545-0366
Practice Address - Street 1:185 TREUHAFT BLVD
Practice Address - Street 2:STE 4
Practice Address - City:BARBOURVILLE
Practice Address - State:KY
Practice Address - Zip Code:40906-8300
Practice Address - Country:US
Practice Address - Phone:606-545-6766
Practice Address - Fax:606-545-0366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-23
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100663490Medicaid