MEDICARE: SKILLZ 4 LIFE, INC.

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	1041S0200X	School Social Worker
2	2251P0200X	Pediatric Physical Therapist
3	235Z00000X	Speech-Language Pathologist
4	225XP0200X	Pediatric Occupational Therapist	R5089	KY

General Provider Information

NPI Number	:	1881044675
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SKILLZ 4 LIFE, INC.

Provider Business Mailing Address
First Line	:	3814 GREENWICH RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40218-1616
Country	:	US
Telephone Number	:	502-855-1271
Fax Number	:

Provider Business Practice Location Address
First Line	:	3814 GREENWICH RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40218-1616
Country	:	US
Telephone Number	:	502-855-1271
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/ OCCUPATIONAL THERAPIST
Name	:	MS. MARLEETA HARRIS
Credential	:	OTR/L
Telephone Number	:	502-855-1271

Provider Enumeration Date	:	06/13/2016
Last Update Date	:	06/13/2016

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Directions to “SKILLZ 4 LIFE, INC. ” Practice Location

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