Provider Demographics
NPI:1912386343
Name:INDEPENDENCE AT HEART LLC
Entity Type:Organization
Organization Name:INDEPENDENCE AT HEART LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KERRIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:ANTHONY
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:502-387-4254
Mailing Address - Street 1:13003 LARKSPUR LN
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-9714
Mailing Address - Country:US
Mailing Address - Phone:502-387-4254
Mailing Address - Fax:
Practice Address - Street 1:13003 LARKSPUR LN
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:KY
Practice Address - Zip Code:40059-9714
Practice Address - Country:US
Practice Address - Phone:502-387-4254
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-18
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR0033225XN1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100338710OtherMEDICAID