Basic Information
| Provider Information | |||||||||
| NPI: | 1992134894 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARSHALL PEDIATRIC THERAPY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 WIND HAVEN DR STE 1 | ||||||||
| Address2: | |||||||||
| City: | NICHOLASVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403568005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592242273 | ||||||||
| FaxNumber: | 8592244675 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 REGENCY RD | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405032302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592242273 | ||||||||
| FaxNumber: | 8592244675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2013 | ||||||||
| LastUpdateDate: | 08/18/2014 | ||||||||
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| AuthorizedOfficialLastName: | MARSHALL | ||||||||
| AuthorizedOfficialFirstName: | PAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8592242273 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OTR/L | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 235Z00000X | 4077 | KY | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225X00000X | R3083 | KY | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.