Provider Demographics
NPI:1558591669
Name:USPIRITUS-BROOKLAWN-SUSAN'S
Entity type:Organization
Organization Name:USPIRITUS-BROOKLAWN-SUSAN'S
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:KATE
Authorized Official - Last Name:O'LEARY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-451-5177
Mailing Address - Street 1:3121 BROOKLAWN CAMPUS DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40218-1282
Mailing Address - Country:US
Mailing Address - Phone:502-451-5177
Mailing Address - Fax:502-451-0896
Practice Address - Street 1:2119 GOLDSMITH LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-1206
Practice Address - Country:US
Practice Address - Phone:502-451-5177
Practice Address - Fax:502-451-0896
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:USPIRITUS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-23
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY950025323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100254670Medicaid