Provider Demographics
NPI:1902092208
Name:MIDLANDS BEHAVIORAL MEDICINE
Entity Type:Organization
Organization Name:MIDLANDS BEHAVIORAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:W
Authorized Official - Last Name:NOELKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-824-5444
Mailing Address - Street 1:1406 N MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:41097
Mailing Address - Country:US
Mailing Address - Phone:859-824-5444
Mailing Address - Fax:859-824-0960
Practice Address - Street 1:1406 N MAIN STREET
Practice Address - Street 2:
Practice Address - City:WILLIAMSTOWN
Practice Address - State:KY
Practice Address - Zip Code:41097
Practice Address - Country:US
Practice Address - Phone:859-824-5444
Practice Address - Fax:859-824-0960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY177103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0964701Medicare UPIN