NPIMap

Organization Active NPI

Wilderness Trace Child Development Center

  • Physical Therapist
  • Danville, KY
National Provider Identifier
1003024084
Registry record updated May 10, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physical TherapistTaxonomy code 225100000X
Legal business name
WILDERNESS TRACE CHILD DEVELOPMENT CENTER
Practice address
409 Stewarts LN N
Danville, KY 40422-8825
Phone
(859) 236-0878
Fax
(859) 236-0878
NPI assigned
May 21, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 10, 2017

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Libby Suttles
Title
Executive Director
Phone
(859) 236-0878

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Physical TherapistGroup: 193200000X MULTI-SPECIALTY GROUP 225100000X Primary
Occupational TherapistGroup: 193200000X MULTI-SPECIALTY GROUP 225X00000X
Speech-Language PathologistGroup: 193200000X MULTI-SPECIALTY GROUP 235Z00000X
Local Education Agency (LEA) 251300000X 354928 KY

Addresses

Primary practice location

409 Stewarts LN N
Danville, KY 40422-8825

Mailing address

409 Stewarts LN N
Danville, KY 40422-8825
Phone (859) 236-0878

Other identifiers 2

IdentifierTypeStateIssuer
7100454490MedicaidKY
00153OtherKYFIRST STEPS PROVIDER NUMB

National Provider Directory

National Provider Directory

Locations

409 Stewarts Ln N
Danville, KY 40422
Phone (859) 236-0878

Practitioners & affiliated clinicians

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1179705600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1494374400000",
    "number": "1003024084",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "409 STEWARTS LN N",
            "city": "DANVILLE",
            "state": "KY",
            "postal_code": "404228825",
            "telephone_number": "859-236-0878",
            "fax_number": "859-236-3570"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "409 STEWARTS LN N",
            "city": "DANVILLE",
            "state": "KY",
            "postal_code": "404228825",
            "telephone_number": "859-236-0878",
            "fax_number": "859-236-0878"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WILDERNESS TRACE CHILD DEVELOPMENT CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-05-21",
        "last_updated": "2017-05-10",
        "status": "A",
        "authorized_official_last_name": "SUTTLES",
        "authorized_official_first_name": "LIBBY",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "859-236-0878",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physical Therapist",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "225X00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Occupational Therapist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "235Z00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Speech-Language Pathologist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "251300000X",
            "taxonomy_group": "",
            "desc": "Local Education Agency (LEA)",
            "state": "KY",
            "license": "354928",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7100454490",
            "state": "KY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "FIRST STEPS PROVIDER NUMB",
            "identifier": "00153",
            "state": "KY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Danville, KY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 10, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.