Healthcare Provider Details

I. General information

NPI: 1083005037
Provider Name (Legal Business Name): THE KID SPOT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2015
Last Update Date: 02/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 CASEY ST STE A
CAMPBELLSVILLE KY
42718-6858
US

IV. Provider business mailing address

121 CASEY ST STE A
CAMPBELLSVILLE KY
42718-6858
US

V. Phone/Fax

Practice location:
  • Phone: 270-465-7768
  • Fax:
Mailing address:
  • Phone: 270-465-7768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number005957
License Number StateKY

VIII. Authorized Official

Name: BRANDY CLOSE
Title or Position: CO-OWNER AND OT
Credential: MS, OTR/L
Phone: 270-465-7768