Provider Demographics
NPI:1255948154
Name:BERGHAUSEN, KATHLEEN B (NP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:B
Last Name:BERGHAUSEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9642 BROWNSBORO RD #154
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-8042
Mailing Address - Country:US
Mailing Address - Phone:502-558-0916
Mailing Address - Fax:502-385-6687
Practice Address - Street 1:417 BENJAMIN LN STE 101
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-4939
Practice Address - Country:US
Practice Address - Phone:502-289-9306
Practice Address - Fax:502-385-6687
Is Sole Proprietor?:No
Enumeration Date:2020-09-25
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3015109363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3015109Medicaid