Healthcare Provider Details

I. General information

NPI: 1003024084
Provider Name (Legal Business Name): WILDERNESS TRACE CHILD DEVELOPMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 05/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 STEWARTS LN N
DANVILLE KY
40422-8825
US

IV. Provider business mailing address

409 STEWARTS LN N
DANVILLE KY
40422-8825
US

V. Phone/Fax

Practice location:
  • Phone: 859-236-0878
  • Fax: 859-236-0878
Mailing address:
  • Phone: 859-236-0878
  • Fax: 859-236-3570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number354928
License Number StateKY

VIII. Authorized Official

Name: MRS. LIBBY SUTTLES
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 859-236-0878