Basic Information
| Provider Information | |||||||||
| NPI: | 1801262134 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAROOK | ||||||||
| FirstName: | MINNAH | ||||||||
| MiddleName: | WAHIDA | ||||||||
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| Credential: | M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2083 FAIRMONT CT | ||||||||
| Address2: | APT 8 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405022019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864845696 | ||||||||
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| Practice Location | |||||||||
| Address1: | 415 GIBSON LN | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404752577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8596265030 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2015 | ||||||||
| LastUpdateDate: | 10/09/2015 | ||||||||
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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 | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1790731081 | 05 | KY | MEDICAID |