Provider Demographics
NPI:1215664586
Name:HINES, MONICA
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:HINES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 STACKER ST
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:KY
Mailing Address - Zip Code:42256-9104
Mailing Address - Country:US
Mailing Address - Phone:270-893-3391
Mailing Address - Fax:
Practice Address - Street 1:130 ALFREDO DR STE A
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042-2750
Practice Address - Country:US
Practice Address - Phone:224-242-3418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-05
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0013688471Medicaid