Basic Information
| Provider Information | |||||||||
| NPI: | 1164558185 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLOUGHBY | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | DENISE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 N EAGLE CREEK DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405091894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592648866 | ||||||||
| FaxNumber: | 8592641167 | ||||||||
| Practice Location | |||||||||
| Address1: | 151 N EAGLE CREEK DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405091894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592648866 | ||||||||
| FaxNumber: | 8592641167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2007 | ||||||||
| LastUpdateDate: | 10/14/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | KY-R2571 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 000000600602 | 01 | KY | BCBS FOR LHT | OTHER |