Provider Demographics
NPI:1124507280
Name:ROTHACKER, KEVIN ANDREW
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:ANDREW
Last Name:ROTHACKER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 SOUTHERN DR
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-2418
Mailing Address - Country:US
Mailing Address - Phone:270-243-3406
Mailing Address - Fax:
Practice Address - Street 1:121 S PUBLIC SQ
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:KY
Practice Address - Zip Code:42743-1532
Practice Address - Country:US
Practice Address - Phone:270-206-2601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-09
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY285474106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist