Provider Demographics
NPI:1811430978
Name:PENTECOSTAL CHILDREN'S HOME
Entity type:Organization
Organization Name:PENTECOSTAL CHILDREN'S HOME
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:TREATMENT DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:R
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:606-546-3805
Mailing Address - Street 1:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:BARBOURVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40906-0550
Mailing Address - Country:US
Mailing Address - Phone:606-546-3805
Mailing Address - Fax:606-546-3903
Practice Address - Street 1:1909 KY 3439
Practice Address - Street 2:
Practice Address - City:BARBOURVILLE
Practice Address - State:KY
Practice Address - Zip Code:40906-7201
Practice Address - Country:US
Practice Address - Phone:606-546-3805
Practice Address - Fax:606-546-3903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-22
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253J00000X
KY8105303245S0500X
KY800232322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No253J00000XAgenciesFoster Care Agency
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children