Provider Demographics
NPI:1417756263
Name:BEANBLOSSOM, RACHEL
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:BEANBLOSSOM
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 1:313 LA GRANGE ROAD
Mailing Address - Street 2:PO BOX: 26
Mailing Address - City:PEWEE VALLEY
Mailing Address - State:KY
Mailing Address - Zip Code:40056
Mailing Address - Country:US
Mailing Address - Phone:502-536-8062
Mailing Address - Fax:
Practice Address - Street 1:116 PERSIMMON RIDGE DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40245-5012
Practice Address - Country:US
Practice Address - Phone:502-536-8062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-12
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY296785106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist