Healthcare Provider Details

I. General information

NPI: 1265932123
Provider Name (Legal Business Name): INTERACTIVE THERAPY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2018
Last Update Date: 03/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 ADAMS ST
ASHLAND KY
41102-6007
US

IV. Provider business mailing address

2801 ADAMS ST
ASHLAND KY
41102-6007
US

V. Phone/Fax

Practice location:
  • Phone: 606-465-9754
  • Fax:
Mailing address:
  • Phone: 606-465-9754
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER C VICE
Title or Position: CO-OWNER
Credential: M.S. CCC-SLP
Phone: 606-465-9754