Provider Demographics
NPI:1780092957
Name:EARLY INTERVENTION AND CONSULTATION SERVICES, LLC
Entity type:Organization
Organization Name:EARLY INTERVENTION AND CONSULTATION SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LASHELL
Authorized Official - Middle Name:ROBIN
Authorized Official - Last Name:LASHLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MAE, MASE,
Authorized Official - Phone:270-868-0089
Mailing Address - Street 1:635 S MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:LEITCHFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42754-1056
Mailing Address - Country:US
Mailing Address - Phone:270-287-0656
Mailing Address - Fax:270-230-0328
Practice Address - Street 1:635 S MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:LEITCHFIELD
Practice Address - State:KY
Practice Address - Zip Code:42754
Practice Address - Country:US
Practice Address - Phone:270-287-0656
Practice Address - Fax:270-230-0328
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:1780092957
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-07-31
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X, 103K00000X, 261QM0855X
KY800280251S00000X, 2080P0006X
KY103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100267230Medicaid
KY7100542910Medicaid