Healthcare Provider Details

I. General information

NPI: 1679903637
Provider Name (Legal Business Name): MARSHALL PEDIATRIC THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2013
Last Update Date: 11/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 PROSPEROUS PL SUITE 24A
LEXINGTON KY
40509-1848
US

IV. Provider business mailing address

105 WIND HAVEN DR STE 1
NICHOLASVILLE KY
40356-8005
US

V. Phone/Fax

Practice location:
  • Phone: 859-224-2273
  • Fax: 859-224-4675
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberR3083
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number4077
License Number StateKY

VIII. Authorized Official

Name: PAM MARSHALL
Title or Position: OWNER
Credential: OTR/L
Phone: 859-224-2273