Provider Demographics
NPI:1033005079
Name:MINDCLUB KENTUCKY LLC
Entity type:Organization
Organization Name:MINDCLUB KENTUCKY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP, CAO
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-390-2865
Mailing Address - Street 1:106 MISSION CT STE 201A
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-6441
Mailing Address - Country:US
Mailing Address - Phone:153-902-8656
Mailing Address - Fax:
Practice Address - Street 1:111 DERRICK PL
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-1325
Practice Address - Country:US
Practice Address - Phone:833-833-9655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-16
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty