Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 103TC2200X | Psychologist | Clinical Child & Adolescent | | | No |
| 2 | 207XP3100X | Orthopaedic Surgery | Pediatric Orthopaedic Surgery | | | No |
| 3 | 225100000X | Physical Therapist | | | | No |
| 4 | 225X00000X | Occupational Therapist | | | | No |
| 5 | 235Z00000X | Speech-Language Pathologist | | | | No |
| 6 | 261QH0100X | Clinic/Center | Health Service | | | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 22000000217778 | OTHER | | ANTHEM BLUE SHIELD ST |
| 2 | 65901993 | MEDICAID | KENTUCKY | |
| 3 | 90630567 | OTHER | KENTUCKY | DME MEDICAID |
| 4 | 200067440A | OTHER | INDIANA | MEDICAID |
| 5 | 22000000217777 | OTHER | | ANTHEM BLUE SHIELD OT |
| 6 | 50006662 | OTHER | KENTUCKY | PASSPORT MD |
| 7 | 22000000217779 | OTHER | | ANTHEM BLUE SHIELD PT |
| 8 | 50000598 | OTHER | KENTUCKY | PASSPORT THERAPY |
