Healthcare Provider Details

I. General information

NPI: 1699112623
Provider Name (Legal Business Name): LOUISVILLE PEDIATRIC THERAPY CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2013
Last Update Date: 04/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9810 BLUEGRASS PKWY
LOUISVILLE KY
40299-1906
US

IV. Provider business mailing address

9810 BLUEGRASS PKWY
LOUISVILLE KY
40299-1906
US

V. Phone/Fax

Practice location:
  • Phone: 502-584-9781
  • Fax: 502-589-2409
Mailing address:
  • Phone: 502-584-9781
  • Fax: 502-589-2409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number100501
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number100501
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number100501
License Number StateKY

VIII. Authorized Official

Name: MS. LAUREN SMITH
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 502-584-9781