Provider Demographics
NPI:1669869327
Name:BLOODWORTH, NICHOLAS WAYNE (LMFT)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:WAYNE
Last Name:BLOODWORTH
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 E 80 DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:KY
Mailing Address - Zip Code:42728-8927
Mailing Address - Country:US
Mailing Address - Phone:270-250-5264
Mailing Address - Fax:
Practice Address - Street 1:441 E 80 DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:KY
Practice Address - Zip Code:42728-8927
Practice Address - Country:US
Practice Address - Phone:270-250-5264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-21
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY240324106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist