Provider Demographics
NPI:1598363822
Name:FM365 THERAPY LLC
Entity Type:Organization
Organization Name:FM365 THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:E
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:MS, OTR/L
Authorized Official - Phone:513-305-0599
Mailing Address - Street 1:400 HILLCREST AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40206-1509
Mailing Address - Country:US
Mailing Address - Phone:513-305-0599
Mailing Address - Fax:
Practice Address - Street 1:400 HILLCREST AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40206-1509
Practice Address - Country:US
Practice Address - Phone:513-305-0599
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100553370Medicaid