Basic Information
| Provider Information | |||||||||
| NPI: | 1366482317 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEW VISTA OF THE BLUEGRASS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BLUEGRASS.ORG INC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1351 NEWTOWN PIKE | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405111275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592531686 | ||||||||
| FaxNumber: | 8592542743 | ||||||||
| Practice Location | |||||||||
| Address1: | 1351 NEWTOWN PIKE | ||||||||
| Address2: | BLDG 5 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405111275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592531686 | ||||||||
| FaxNumber: | 8592542743 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 10/12/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WERLINE | ||||||||
| AuthorizedOfficialFirstName: | DEE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 8592531686 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 800121 | KY | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 091018 | 01 | KY | VALUE OPTIONS | OTHER | 000000057414 | 01 | KY | ANTHEM | OTHER | 28015014 | 05 | KY | MEDICAID | 203628000 | 01 | KY | MAGELLAN 221 | OTHER | 101483 | 01 | KY | CHA INSURANCE | OTHER | 27015015 | 05 | KY | MEDICAID | 29000003 | 05 | KY | MEDICAID | 33900119 | 05 | KY | MEDICAID | 242395 | 01 | KY | COMPSYCH | OTHER | 207023 | 01 | KY | MHN | OTHER | 30615058 | 05 | KY | MEDICAID | 874068 | 01 | KY | USA | OTHER |