Healthcare Provider Details

I. General information

NPI: 1710127840
Provider Name (Legal Business Name): MS. TRACEY FARRELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2009
Last Update Date: 11/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 GOLDSMITH LN
LOUISVILLE KY
40218
US

IV. Provider business mailing address

1906 GOLDSMITH LN
LOUISVILLE KY
40218-2066
US

V. Phone/Fax

Practice location:
  • Phone: 502-636-3207
  • Fax: 502-636-0024
Mailing address:
  • Phone: 502-498-2927
  • Fax: 502-498-2946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License NumberKIE
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: