Basic Information
| Provider Information | |||||||||
| NPI: | 1104198472 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARSHALL PEDIATRIC THERAPY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 WIND HAVEN DR | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | NICHOLASVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403568005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592242273 | ||||||||
| FaxNumber: | 8592244675 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 WIND HAVEN DR | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | NICHOLASVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403568005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592242273 | ||||||||
| FaxNumber: | 8592244675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2012 | ||||||||
| LastUpdateDate: | 05/05/2015 | ||||||||
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| AuthorizedOfficialLastName: | MARSHALL | ||||||||
| AuthorizedOfficialFirstName: | PAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | OCCUPATIONAL THERAPIST / OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8592242273 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 1196 | KY | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 225100000X | 5326 | KY | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225XP0019X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Physical Rehabilitation | 235Z00000X | 4077 | KY | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225XP0200X | R3083 | KY | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 7100205670 | 05 | KY | MEDICAID | 7100299670 | 05 | KY | MEDICAID | 7100215800 | 05 | KY | MEDICAID | 7100278210 | 05 | KY | MEDICAID |