Provider Demographics
NPI:1619366101
Name:BLUEGRASS CENTER FOR AUTISM
Entity Type:Organization
Organization Name:BLUEGRASS CENTER FOR AUTISM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-719-9944
Mailing Address - Street 1:1250 BARDSTOWN RD
Mailing Address - Street 2:STE 15
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204-1333
Mailing Address - Country:US
Mailing Address - Phone:502-618-3334
Mailing Address - Fax:502-709-9892
Practice Address - Street 1:9810 BLUEGRASS PKWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-1906
Practice Address - Country:US
Practice Address - Phone:502-473-7219
Practice Address - Fax:502-709-9892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-21
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty