Provider Demographics
NPI:1306250782
Name:FOOTHILLS ACADEMY, INC
Entity type:Organization
Organization Name:FOOTHILLS ACADEMY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:606-343-0216
Mailing Address - Street 1:80 ROLLING HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:KY
Mailing Address - Zip Code:42633-9005
Mailing Address - Country:US
Mailing Address - Phone:606-343-0216
Mailing Address - Fax:606-343-0224
Practice Address - Street 1:80 ROLLING HILLS BLVD
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:KY
Practice Address - Zip Code:42633-9005
Practice Address - Country:US
Practice Address - Phone:606-343-0216
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOOTHILLS ACADEMY, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-13
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM1300X
KYLPCPCC00216418101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100317630Medicaid