| Changed Lives Substance Abuse Treatment | |
|
149 Deweese St Lexington KY 40507-1925 | |
| (859) 368-4105 | |
| Not Available |
| Full Name | Changed Lives Substance Abuse Treatment |
|---|---|
| Speciality | Counselor |
| Location | 149 Deweese St, Lexington, Kentucky |
| Authorized Official Name and Position | Christopher T Cox (OWNER) |
| Authorized Official Contact | 8593684105 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Changed Lives Substance Abuse Treatment 149 Deweese St Lexington KY 40507-1925 Ph: () - | Changed Lives Substance Abuse Treatment 149 Deweese St Lexington KY 40507-1925 Ph: (859) 368-4105 |
| NPI Number | 1609412618 |
|---|---|
| Provider Enumeration Date | 11/25/2019 |
| Last Update Date | 11/02/2020 |
| Certification Date | 11/02/2020 |
| Medicare PECOS PAC ID | 8729494190 |
|---|---|
| Medicare Enrollment ID | O20210309002808 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1609412618 | NPI | - | NPPES |
| 246158 | Other | KY | LCADC |
| 266252 | Other | KY | LPCC |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YM0800X | Counselor - Mental Health | (* (Not Available)) | Primary |
| Provider Name | Jessica Duval |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1295236537 PECOS PAC ID: 3870909245 Enrollment ID: I20210309002995 |
| Provider Name | Miranda Hagan |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1003404534 PECOS PAC ID: 7214346469 Enrollment ID: I20210429001767 |
| Provider Name | Benjamin Marshall |
|---|---|
| Provider Type | Practitioner - Addiction Medicine |
| Provider Identifiers | NPI Number: 1740574052 PECOS PAC ID: 3577962364 Enrollment ID: I20210527001522 |
| Provider Name | Vicky Casey |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1568012227 PECOS PAC ID: 8325440480 Enrollment ID: I20210712002925 |
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