Healthcare Provider Details

I. General information

NPI: 1093220741
Provider Name (Legal Business Name): BLANFORD PEDIATRIC THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2017
Last Update Date: 08/31/2023
Certification Date: 08/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 S 5TH ST
BARDSTOWN KY
40004-1142
US

IV. Provider business mailing address

201 S 5TH ST
BARDSTOWN KY
40004-1142
US

V. Phone/Fax

Practice location:
  • Phone: 502-331-5478
  • Fax: 502-385-0234
Mailing address:
  • Phone: 502-331-5478
  • Fax: 502-385-0234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: ANGIE BOLTWOOD
Title or Position: BILLING MANAGER
Credential:
Phone: 770-530-9051