Provider Demographics
NPI:1659669968
Name:KENTUCKY EARLY INTERVENTION SERVICES
Entity Type:Organization
Organization Name:KENTUCKY EARLY INTERVENTION SERVICES
Other - Org Name:STATE FIRST STEPS PROGRAM
Other - Org Type:Other Name
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:G
Authorized Official - Last Name:FAWBUSH
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN
Authorized Official - Phone:502-564-3756
Mailing Address - Street 1:275 E MAIN ST
Mailing Address - Street 2:HS 2W-C
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601-2321
Mailing Address - Country:US
Mailing Address - Phone:502-564-3456
Mailing Address - Fax:502-564-8003
Practice Address - Street 1:275 E MAIN ST
Practice Address - Street 2:HS 2W-C
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601-2321
Practice Address - Country:US
Practice Address - Phone:502-564-3456
Practice Address - Fax:502-564-8003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-20
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY24000028Medicaid