| Mandala House | |
|
633 Baxter Ave Louisville KY 40204-1157 | |
| (502) 309-2408 | |
| (502) 771-4283 |
| Full Name | Mandala House |
|---|---|
| Speciality | Psychologist |
| Location | 633 Baxter Ave, Louisville, Kentucky |
| Authorized Official Name and Position | Jacks Gilles (EXECUTIVE DIRECTOR) |
| Authorized Official Contact | 5023092403 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Mandala House 633 Baxter Ave Louisville KY 40204-1157 Ph: (502) 309-2403 | Mandala House 633 Baxter Ave Louisville KY 40204-1157 Ph: (502) 309-2408 |
| NPI Number | 1659829760 |
|---|---|
| Provider Enumeration Date | 09/18/2016 |
| Last Update Date | 09/30/2024 |
| Certification Date | 09/30/2024 |
| Medicare PECOS PAC ID | 4789957135 |
|---|---|
| Medicare Enrollment ID | O20170906002088 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1659829760 | NPI | - | NPPES |
| 1659829760 | Other | KY | NPI |
| 7100489150 | Medicaid | KY |
| Provider Name | David E Kissel |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1609883354 PECOS PAC ID: 8325134745 Enrollment ID: I20071017000321 |
| Provider Name | Christopher C Tyler |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1497935324 PECOS PAC ID: 5799815171 Enrollment ID: I20100610001089 |
| Provider Name | Barbara S Keys |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1871828004 PECOS PAC ID: 6507091436 Enrollment ID: I20131031001500 |
| Provider Name | Bethany D Simon |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1154757953 PECOS PAC ID: 0941428692 Enrollment ID: I20140821002522 |
| Provider Name | Jennifer Lynn Gordon |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1235511072 PECOS PAC ID: 1759693500 Enrollment ID: I20150707003377 |
| Provider Name | Catherine Joy Messinger |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1811957350 PECOS PAC ID: 0345282885 Enrollment ID: I20160318001526 |
| Provider Name | Aaron Levinsky |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1720360720 PECOS PAC ID: 1052694148 Enrollment ID: I20170215002866 |
| Provider Name | Adrianne Lange |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1457671232 PECOS PAC ID: 0648541813 Enrollment ID: I20170807000635 |
| Provider Name | Jacquelyn M Gilles |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1124212972 PECOS PAC ID: 9133492580 Enrollment ID: I20170913002014 |
| Provider Name | Kennetha Alma Marie Williams |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1366787798 PECOS PAC ID: 8123451473 Enrollment ID: I20191127001911 |
| Provider Name | Ariel Brooks |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1558610626 PECOS PAC ID: 6305257742 Enrollment ID: I20201116002227 |
| Provider Name | David Schroerlucke |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1598071474 PECOS PAC ID: 5890108286 Enrollment ID: I20201231001867 |
| Provider Name | Jordan Ford |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1477146157 PECOS PAC ID: 2062828189 Enrollment ID: I20210315001437 |
| Provider Name | Natalie Berry |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1578225728 PECOS PAC ID: 8426426750 Enrollment ID: I20221117002481 |
| Provider Name | Andrew Hickman |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1346939675 PECOS PAC ID: 1254790363 Enrollment ID: I20230707002438 |
| Provider Name | Jasmine Wadkins |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1578867958 PECOS PAC ID: 2365898558 Enrollment ID: I20231024002846 |
| Provider Name | Clairemarie Locicero |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1750153177 PECOS PAC ID: 6204284177 Enrollment ID: I20231204000506 |
| Provider Name | Michael May |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1528491685 PECOS PAC ID: 9830542943 Enrollment ID: I20240125000161 |
| Provider Name | Kimberly Paul |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1629542410 PECOS PAC ID: 5698119923 Enrollment ID: I20240214004175 |
| Provider Name | Lucie Erlebachova |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1053548990 PECOS PAC ID: 1658710769 Enrollment ID: I20240422001425 |
| Provider Name | Rachel Archer |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1053924845 PECOS PAC ID: 4688117930 Enrollment ID: I20240614003340 |
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