Provider Demographics
NPI:1588085799
Name:MEDIATION & COUNSELING CENTER OF WESTERN KENTUCKY, INC.
Entity type:Organization
Organization Name:MEDIATION & COUNSELING CENTER OF WESTERN KENTUCKY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BAIZE
Authorized Official - Suffix:SR
Authorized Official - Credentials:MPSYCH, CCCT, CPC
Authorized Official - Phone:270-852-6516
Mailing Address - Street 1:2400 FRIENDSHIP DR STE B
Mailing Address - Street 2:RONALD LOGSDON COMMUNITY CENTER AT PRESIDENTS PLACE
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-3011
Mailing Address - Country:US
Mailing Address - Phone:270-852-6516
Mailing Address - Fax:270-683-9771
Practice Address - Street 1:2400 FRIENDSHIP DR STE B
Practice Address - Street 2:2400 FRIENDSHIP DRIVE, SUITE B
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-3011
Practice Address - Country:US
Practice Address - Phone:270-852-6516
Practice Address - Fax:270-683-9771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-16
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health