Provider Demographics
NPI:1548035223
Name:HOME AWAY FROM HOME THERAPEUTIC CENTER
Entity type:Organization
Organization Name:HOME AWAY FROM HOME THERAPEUTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWENER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHAQUILA
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:DSW, LCSW
Authorized Official - Phone:502-618-9205
Mailing Address - Street 1:1828 BOLLING AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40210-1908
Mailing Address - Country:US
Mailing Address - Phone:502-618-9205
Mailing Address - Fax:
Practice Address - Street 1:849 S 37TH ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40211-2811
Practice Address - Country:US
Practice Address - Phone:502-618-9204
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-22
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty