Basic Information
| Provider Information | |||||||||
| NPI: | 1396870804 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEDIGO | ||||||||
| FirstName: | LEREASA | ||||||||
| MiddleName: | LYNNE | ||||||||
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| Credential: | CADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 410 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SCOTTSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421641126 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 822 WOODWAY ST | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421012771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2709015000 | ||||||||
| FaxNumber: | 2708420721 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 0272 | KY | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 30604011 | 05 | KY | MEDICAID |