=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811503337
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKE CUMBERLAND PEDIATRIC THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2020
-----------------------------------------------------
Last Update Date | 09/28/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 67 JACKS LN
-----------------------------------------------------
City | SOMERSET
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42501-6152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-425-4371
-----------------------------------------------------
Fax | 606-699-1669
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 67 JACKS LN
-----------------------------------------------------
City | SOMERSET
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42501-6152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-425-4371
-----------------------------------------------------
Fax | 606-699-1669
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | CYNTHIA C JONES
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 606-425-4371
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------