Provider Demographics
NPI:1154524155
Name:NORTHERN KENTUCKY MHMR REGIONAL BOARD
Entity type:Organization
Organization Name:NORTHERN KENTUCKY MHMR REGIONAL BOARD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:OWEN
Authorized Official - Middle Name:T
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:859-578-3200
Mailing Address - Street 1:502 FARRELL DRIVE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011
Mailing Address - Country:US
Mailing Address - Phone:859-578-3200
Mailing Address - Fax:
Practice Address - Street 1:503 FARRELL DR
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41011-3775
Practice Address - Country:US
Practice Address - Phone:859-578-3200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHERN KY MHMR REGIONAL BOARD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-07
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QA0600X
KY800084261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100735970Medicaid
KY27007012Medicaid