=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427183276
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIRST CLASS CHILD CARE PLACE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4910 SIMPSON DRIVE
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-553-0360
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 18735
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40261-0735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-553-0360
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-DIRECTOR
-----------------------------------------------------
Name | MRS. PHOEBE ROSIMO WILLIAMSON
-----------------------------------------------------
Credential | M.S.-CCC,SLP
-----------------------------------------------------
Telephone | 502-553-0360
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 1921
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------