Provider Demographics
NPI:1164558185
Name:WILLOUGHBY, LAURA DENISE (OT)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:DENISE
Last Name:WILLOUGHBY
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 N EAGLE CREEK DR STE 400
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-1894
Mailing Address - Country:US
Mailing Address - Phone:859-264-8866
Mailing Address - Fax:859-264-1167
Practice Address - Street 1:151 N EAGLE CREEK DR STE 400
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1894
Practice Address - Country:US
Practice Address - Phone:859-264-8866
Practice Address - Fax:859-264-1167
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-R2571225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000600602OtherBCBS FOR LHT
KY000000600602OtherBCBS FOR LHT
0718410Medicare PIN