Basic Information
| Provider Information | |||||||||
| NPI: | 1891210159 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HOPEBRIDGE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3500 DEPAUW BLVD STE 3070 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462686135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173768336 | ||||||||
| FaxNumber: | 3174494835 | ||||||||
| Practice Location | |||||||||
| Address1: | 2904 FOLTZ DR | ||||||||
| Address2: | |||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410172525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553240885 | ||||||||
| FaxNumber: | 7654506664 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2017 | ||||||||
| LastUpdateDate: | 05/09/2018 | ||||||||
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| AuthorizedOfficialLastName: | MAY | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3177943211 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HOPEBRIDGE, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TH0100X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Health Service | 106E00000X | N | 193200000X MULTI-SPECIALTY GROUP | 106S00000X | N | 193200000X MULTI-SPECIALTY GROUP | 2084P0804X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 7100473020 | 05 | KY | MEDICAID |