=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033503974
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMONWEALTH THERAPY LOUISVILLE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2015
-----------------------------------------------------
Last Update Date | 12/01/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3703 TAYLORSVILLE RD STE 211
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40220-1331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-592-1736
-----------------------------------------------------
Fax | 502-785-4834
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3703 TAYLORSVILLE RD STE 221
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40220-1331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-592-1736
-----------------------------------------------------
Fax | 502-785-4834
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST/OWNER
-----------------------------------------------------
Name | ALLYSON BRADOW
-----------------------------------------------------
Credential | PSY.D
-----------------------------------------------------
Telephone | 502-592-1736
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------