Healthcare Provider Details

I. General information

NPI: 1306698535
Provider Name (Legal Business Name): MAKING WAVES PEDIATRIC THERAPY SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2024
Last Update Date: 04/02/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4103 BOLLING BROOK DRIVE
LOUISVILLE KY
40299
US

IV. Provider business mailing address

4103 BOLLING BROOK DRIVE
LOUISVILLE KY
40299
US

V. Phone/Fax

Practice location:
  • Phone: 859-492-7257
  • Fax:
Mailing address:
  • Phone: 859-492-7257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MELODY PRINKLETON
Title or Position: OWNER/ORGANIZER
Credential: PT
Phone: 859-492-7257