Provider Demographics
NPI:1811054380
Name:BEMKER - PAGE, MARY
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:BEMKER - PAGE
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:A
Other - Last Name:BEMKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYS, DSN
Mailing Address - Street 1:2100 GARDINER LN
Mailing Address - Street 2:SUITE 314
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-2962
Mailing Address - Country:US
Mailing Address - Phone:502-457-7719
Mailing Address - Fax:
Practice Address - Street 1:2100 GARDINER LN
Practice Address - Street 2:SUITE 314
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-2962
Practice Address - Country:US
Practice Address - Phone:502-457-7719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY101YA0400X
KYKY-0107101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional