Provider Demographics
NPI:1336404912
Name:SPECIALIZED THERAPY GROUP, LLC
Entity Type:Organization
Organization Name:SPECIALIZED THERAPY GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-FOUNDER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:II
Authorized Official - Credentials:RAS-I, CART
Authorized Official - Phone:606-420-4070
Mailing Address - Street 1:340 17TH ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-7628
Mailing Address - Country:US
Mailing Address - Phone:606-420-4070
Mailing Address - Fax:606-420-4071
Practice Address - Street 1:340 17TH ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-7628
Practice Address - Country:US
Practice Address - Phone:606-420-4070
Practice Address - Fax:606-420-4071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-10
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI-C1112181215101YA0400X
KY0864101YM0800X
2084P0800X
KY29912261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64106826Medicaid
KY1971901Medicare PIN
KYH45449Medicare UPIN