Provider Demographics
NPI:1093220741
Name:BLANFORD PEDIATRIC THERAPY LLC
Entity Type:Organization
Organization Name:BLANFORD PEDIATRIC THERAPY LLC
Other - Org Name:LEMON-AID MENTAL HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLTWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-530-9051
Mailing Address - Street 1:201 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-1142
Mailing Address - Country:US
Mailing Address - Phone:502-331-5478
Mailing Address - Fax:502-385-0234
Practice Address - Street 1:201 S 5TH ST
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-1142
Practice Address - Country:US
Practice Address - Phone:502-331-5478
Practice Address - Fax:502-385-0234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-04
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100424590Medicaid