Healthcare Provider Details

I. General information

NPI: 1639526940
Provider Name (Legal Business Name): CHILDREN1ST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2016
Last Update Date: 05/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 HOLIDAY COURT
ELIZABETHTOWN KY
42701-8809
US

IV. Provider business mailing address

104 HOLIDAY CT
ELIZABETHTOWN KY
42701-6490
US

V. Phone/Fax

Practice location:
  • Phone: 270-300-2044
  • Fax: 270-360-3271
Mailing address:
  • Phone: 270-300-2044
  • Fax: 270-360-3271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License NumberEDSP 71846
License Number StateKY

VIII. Authorized Official

Name: MRS. TRACEY LYNNE FOWL
Title or Position: DEVELOPMENTAL INTERVENTIONIST
Credential: MASTERS SPECIAL ED
Phone: 270-300-2044