Healthcare Provider Details

I. General information

NPI: 1558741884
Provider Name (Legal Business Name): THE KID SPOT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2015
Last Update Date: 06/02/2015
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: 270-465-0068
Mailing address:
  • Phone: 270-465-7768
  • Fax: 270-465-0068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLPINP00216172
License Number StateKY

VIII. Authorized Official

Name: MRS. MICHELLE ELIZABETH TRAVIS
Title or Position: SPEECH-LANGUAGE PATHOLOGIST
Credential: M.S., CF-SLP
Phone: 270-576-1610