Provider Demographics
NPI:1184423808
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:502-443-3836
Mailing Address - Street 1:9300 CEDAR CENTER WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40291-4522
Mailing Address - Country:US
Mailing Address - Phone:502-473-7219
Mailing Address - Fax:502-709-9892
Practice Address - Street 1:9300 CEDAR CENTER WAY STE 200
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40291-4522
Practice Address - Country:US
Practice Address - Phone:502-473-7219
Practice Address - Fax:502-709-9892
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLUEGRASS CENTER FOR AUTISM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-03-13
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100700160Medicaid