Provider Demographics
NPI:1174065627
Name:NEBERGALL, MARY (LPCC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:NEBERGALL
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 FARRELL DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-3717
Mailing Address - Country:US
Mailing Address - Phone:859-578-3204
Mailing Address - Fax:859-578-3273
Practice Address - Street 1:513 MADISON AVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41011-1505
Practice Address - Country:US
Practice Address - Phone:859-578-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-15
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY248448101YP2500X, 101YM0800X
KY260363221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY610661458OtherTAX ID