Provider Demographics
NPI:1407879349
Name:WENDELL FOSTER'S CAMPUS FOR DEVELOPMENTAL DISABILITIES
Entity Type:Organization
Organization Name:WENDELL FOSTER'S CAMPUS FOR DEVELOPMENTAL DISABILITIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:BETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:SHEPHERD
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:270-852-1425
Mailing Address - Street 1:815 TRIPLETT ST
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-3564
Mailing Address - Country:US
Mailing Address - Phone:270-683-4517
Mailing Address - Fax:270-683-0079
Practice Address - Street 1:815 TRIPLETT ST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-3564
Practice Address - Country:US
Practice Address - Phone:270-683-4517
Practice Address - Fax:270-683-0079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY225100000X, 225X00000X, 235Z00000X, 261QM0850X, 261QR0401X, 315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty
No261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)Group - Multi-Specialty
No315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual DisabilitiesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100343070Medicaid
KY45118379Medicaid
KY7100337840Medicaid
KY7100427110Medicaid
KY184517Other184517
KY33000035Medicaid
KY11903135Medicaid
KY7100344330Medicaid