Provider Demographics
NPI:1164970448
Name:HEARTLAND WHOLE BRAIN LEARNING-PEDIATRIC & ADULT THERAPY LLC
Entity Type:Organization
Organization Name:HEARTLAND WHOLE BRAIN LEARNING-PEDIATRIC & ADULT THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH -LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:BEASLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MSCCC-SLP
Authorized Official - Phone:270-982-7246
Mailing Address - Street 1:109 ROBINSON CT
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-9247
Mailing Address - Country:US
Mailing Address - Phone:270-401-2737
Mailing Address - Fax:270-982-3670
Practice Address - Street 1:1239 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2770
Practice Address - Country:US
Practice Address - Phone:270-401-2737
Practice Address - Fax:270-982-3670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-15
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY222Q00000X, 225100000X, 225X00000X
KY142550235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100348760Medicaid
KY1366753980OtherTRICARE NORTH