Healthcare Provider Details

I. General information

NPI: 1104709104
Provider Name (Legal Business Name): BLUEGRASS SPEECH & SWALLOWING OUTPATIENT THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2025
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 W 7TH ST STE 203
LONDON KY
40741-1763
US

IV. Provider business mailing address

452 BRANNON MILL RD
LILY KY
40740-3504
US

V. Phone/Fax

Practice location:
  • Phone: 606-309-4982
  • Fax:
Mailing address:
  • Phone: 606-309-4982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: KAILYN BAKER
Title or Position: OWNER/SPEECH LANGUAGE PATHOLOGIST
Credential: CCC-SLP
Phone: 606-309-4982