| Cleanse Clinic, Pllc | |
|
645 S Roy Wilkins Ave Ste 100 Louisville KY 40203-2072 | |
| (502) 583-4092 | |
| (502) 371-6110 |
| Full Name | Cleanse Clinic, Pllc |
|---|---|
| Speciality | Psychiatry & Neurology |
| Location | 645 S Roy Wilkins Ave Ste 100, Louisville, Kentucky |
| Authorized Official Name and Position | Margaret Groll (BUSINESS MANAGER) |
| Authorized Official Contact | 8129874330 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Cleanse Clinic, Pllc 720 W Broadway Ste 202 Louisville KY 40202-3245 Ph: (502) 561-0943 | Cleanse Clinic, Pllc 645 S Roy Wilkins Ave Ste 100 Louisville KY 40203-2072 Ph: (502) 583-4092 |
| NPI Number | 1659726628 |
|---|---|
| Provider Enumeration Date | 04/27/2016 |
| Last Update Date | 08/13/2024 |
| Certification Date | 08/13/2024 |
| Medicare PECOS PAC ID | 1759630320 |
|---|---|
| Medicare Enrollment ID | O20191118002369 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1659726628 | NPI | - | NPPES |
| 7100413630 | Medicaid | KY |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 2084P0802X | Psychiatry & Neurology - Addiction Psychiatry | 800212 (Kentucky) | Primary |
| Provider Name | Tehmina A Khan |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1477503019 PECOS PAC ID: 5799747705 Enrollment ID: I20041102000426 |
| Provider Name | Suhail Haque |
|---|---|
| Provider Type | Practitioner - Pain Management |
| Provider Identifiers | NPI Number: 1821048513 PECOS PAC ID: 9234165416 Enrollment ID: I20050711000174 |
| Provider Name | Christina M Rollins |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1700956109 PECOS PAC ID: 1759302532 Enrollment ID: I20051208000067 |
| Provider Name | Asad Ismail |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1144227026 PECOS PAC ID: 7214926195 Enrollment ID: I20090427000463 |
| Provider Name | Jaleel Durrani |
|---|---|
| Provider Type | Practitioner - Anesthesiology |
| Provider Identifiers | NPI Number: 1790767945 PECOS PAC ID: 5193701894 Enrollment ID: I20131218001275 |
| Provider Name | Angela Urhammer |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1881839108 PECOS PAC ID: 7012195134 Enrollment ID: I20150817002834 |
| Provider Name | Sarah Ann Thomas |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1629445705 PECOS PAC ID: 4486962693 Enrollment ID: I20151007001449 |
| Provider Name | Amber C Curry |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1093235079 PECOS PAC ID: 8123392867 Enrollment ID: I20170920000226 |
| Provider Name | Nicole Kristina Dozsa |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1700496569 PECOS PAC ID: 0648679365 Enrollment ID: I20210601001307 |
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