Provider Demographics
NPI:1508645359
Name:KENTUCKY INTEGRATIVE AUTISM SPECIALIST
Entity Type:Organization
Organization Name:KENTUCKY INTEGRATIVE AUTISM SPECIALIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-592-4992
Mailing Address - Street 1:1750 THATCHERS MILL RD
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:KY
Mailing Address - Zip Code:40361-9110
Mailing Address - Country:US
Mailing Address - Phone:859-592-4992
Mailing Address - Fax:
Practice Address - Street 1:1750 THATCHERS MILL RD
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:KY
Practice Address - Zip Code:40361-9110
Practice Address - Country:US
Practice Address - Phone:859-592-4992
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-21
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty