Provider Demographics
NPI:1083135636
Name:BACK, WILLIAM DAVID (LPCC, TACDC)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:DAVID
Last Name:BACK
Suffix:
Gender:M
Credentials:LPCC, TACDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 S MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:VERSAILLES
Mailing Address - State:KY
Mailing Address - Zip Code:40383-1582
Mailing Address - Country:US
Mailing Address - Phone:859-489-6557
Mailing Address - Fax:859-756-6078
Practice Address - Street 1:101 SAINT CLAIR ST # A
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601-2640
Practice Address - Country:US
Practice Address - Phone:859-489-6557
Practice Address - Fax:859-756-6078
Is Sole Proprietor?:No
Enumeration Date:2017-07-05
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY162868101YP2500X
KY168467101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)