Basic Information
Provider Information | |||||||||
NPI: | 1306170410 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WELLMAN | ||||||||
FirstName: | SARAH | ||||||||
MiddleName: | ELIZABETH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PSYD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 614 | ||||||||
Address2: |   | ||||||||
City: | HOPKINSVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 422410614 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2708862205 | ||||||||
FaxNumber: | 2708860392 | ||||||||
Practice Location | |||||||||
Address1: | 3999 FORT CAMPBELL BLVD | ||||||||
Address2: |   | ||||||||
City: | HOPKINSVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 422404929 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2708862205 | ||||||||
FaxNumber: | 2708860392 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/22/2009 | ||||||||
LastUpdateDate: | 07/21/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PSYLIP00211375 | KY | Y |   | Behavioral Health & Social Service Providers | Psychologist |   |
ID Information
ID | Type | State | Issuer | Description | 7100296640 | 05 | KY |   | MEDICAID |