Provider Demographics
NPI:1104198472
Name:MARSHALL PEDIATRIC THERAPY, LLC
Entity Type:Organization
Organization Name:MARSHALL PEDIATRIC THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:859-224-2273
Mailing Address - Street 1:105 WIND HAVEN DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-8005
Mailing Address - Country:US
Mailing Address - Phone:859-224-2273
Mailing Address - Fax:859-224-4675
Practice Address - Street 1:105 WIND HAVEN DR
Practice Address - Street 2:SUITE 1
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-8005
Practice Address - Country:US
Practice Address - Phone:859-224-2273
Practice Address - Fax:859-224-4675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-02
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1196101YP2500X
KY5326225100000X
225X00000X, 225XP0019X
KYR3083225XP0200X
KY4077235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical RehabilitationGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100205670Medicaid
KY7100299670Medicaid
KY7100215800Medicaid
KY7100278210Medicaid
KYK041170Medicare PIN
KYK041171Medicare PIN