Provider Demographics
NPI:1669463170
Name:PROFESSIONAL REHABILITATION ASSOCIATES, PSC
Entity type:Organization
Organization Name:PROFESSIONAL REHABILITATION ASSOCIATES, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:859-625-0001
Mailing Address - Street 1:5027 ATWOOD DR STE 2B
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-8322
Mailing Address - Country:US
Mailing Address - Phone:859-625-0001
Mailing Address - Fax:895-625-1109
Practice Address - Street 1:5027 ATWOOD DR STE 2B
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-8322
Practice Address - Country:US
Practice Address - Phone:859-625-0001
Practice Address - Fax:895-625-1109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-03
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2251E1300X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251E1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistElectrophysiology, ClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000190632OtherBC/BS P-EMG
KY47015OtherNGS PARIS
KY000000215122OtherBC/BS SPTA
KY000000310944OtherBC/BS RPTA
KY000000060027OtherBC/BS LPTA
KY42858OtherNSG RPTA
KY4378OtherNGS LPTA
KY000000333709OtherBC/BS HPTA
KY87900312Medicaid
KY000000199364OtherBC/BS PARIS
KY11128OtherNGS HPTA
KY47016OtherNSG SPTA
KYDB9812OtherRAILROAD MCR
KY4378OtherNGS LPTA
KY7053Medicare ID - Type UnspecifiedSTANFORD PHYSICAL THERAPY
KY000000310944OtherBC/BS RPTA
KY47015OtherNGS PARIS
KY8847Medicare ID - Type UnspecifiedPARIS PHYSICAL THERAPY
KY87900312Medicaid