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General NPI Number Information
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NPI Number | 1063202794
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Entity Type | Organization
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Legal Business Name | SQUARE ONE LLC
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Dates
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Enumeration Date | 05/07/2025
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Last Update Date | 05/07/2025
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Provider Practice Location Address
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Address Line | 6440 DUTCHMANS PKWY FL 2
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City | LOUISVILLE
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State | KY
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Zip | 40205-3352
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Country | US
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Telephone | 502-896-2606
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Fax | 502-896-0487
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Provider Business Mailing Address
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Address Line | 6440 DUTCHMANS PKWY FL 2
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City | LOUISVILLE
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State | KY
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Zip | 40205-3352
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Country | US
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Telephone | 502-896-2606
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | CASSIDY NIEHAUS
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Credential |
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Telephone | 502-896-2606
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 2080P0006X
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Taxonomy Name | Developmental - Behavioral Pediatrics Physician
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License Number |
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License Number State |
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