=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164209607
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BREATH AND BALANCE PEDIATRIC THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2023
-----------------------------------------------------
Last Update Date | 02/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 E REYNOLDS RD STE 3
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40517-1251
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-282-3503
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 CARPENTER CREEK RD
-----------------------------------------------------
City | PARKSVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40464-9090
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, OCCUPATIONAL THERAPIST
-----------------------------------------------------
Name | AIMEE LEE DAVIS
-----------------------------------------------------
Credential | MS OTR/L CIMC
-----------------------------------------------------
Telephone | 606-282-3503
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------