MEDICARE: MARSHALL PEDIATRIC THERAPY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist
2	235Z00000X	Speech-Language Pathologist	4077	KY
3	225X00000X	Occupational Therapist	R3083	KY

General Provider Information

NPI Number	:	1598194037
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARSHALL PEDIATRIC THERAPY, LLC

Provider Business Mailing Address
First Line	:	105 WIND HAVEN DR
Second Line	:	SUITE 1
City	:	NICHOLASVILLE
State	:	KY
Zip	:	40356-8005
Country	:	US
Telephone Number	:	859-224-2273
Fax Number	:	859-224-4675

Provider Business Practice Location Address
First Line	:	3260 BLAZER PKWY STE 100
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40509-2116
Country	:	US
Telephone Number	:	859-224-2273
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	PAM MARSHALL
Credential	:	OTR/L
Telephone Number	:	859-224-2273

Provider Enumeration Date	:	11/05/2013
Last Update Date	:	08/28/2014

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