Healthcare Provider Details

I. General information

NPI: 1346951738
Provider Name (Legal Business Name): EARLY INTERVENTION FOR LITTLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2022
Last Update Date: 12/07/2022
Certification Date: 12/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7891 N DIXIE HWY
BONNIEVILLE KY
42713-8308
US

IV. Provider business mailing address

7891 N DIXIE HWY
BONNIEVILLE KY
42713-8308
US

V. Phone/Fax

Practice location:
  • Phone: 270-537-5600
  • Fax:
Mailing address:
  • Phone: 270-537-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: MARIBROOKE J SULLIVAN WALTERS
Title or Position: OWNER
Credential:
Phone: 270-537-5600