Provider Demographics
NPI:1306289293
Name:GLOW THERAPEUTIC SERVICES OF KENTUCKY, LLC
Entity type:Organization
Organization Name:GLOW THERAPEUTIC SERVICES OF KENTUCKY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OUTPATIENT THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:S
Authorized Official - Last Name:HUBERT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, CADC
Authorized Official - Phone:812-453-8543
Mailing Address - Street 1:210 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-4121
Mailing Address - Country:US
Mailing Address - Phone:812-453-8543
Mailing Address - Fax:270-906-1150
Practice Address - Street 1:210 W 3RD ST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-4121
Practice Address - Country:US
Practice Address - Phone:812-453-8543
Practice Address - Fax:270-906-1150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-10
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0981251S00000X
KY3407251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP400019932OtherMEDICARE
KY30603013Medicaid