Provider Demographics
NPI:1063157899
Name:LAUNCH THERAPY CLINIC
Entity type:Organization
Organization Name:LAUNCH THERAPY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PATRICK
Authorized Official - Suffix:
Authorized Official - Credentials:OTD, OTR/L
Authorized Official - Phone:270-893-5600
Mailing Address - Street 1:610 GREEN VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42276-8808
Mailing Address - Country:US
Mailing Address - Phone:270-893-5600
Mailing Address - Fax:
Practice Address - Street 1:314 HIGHLAND LICK RD
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:KY
Practice Address - Zip Code:42276-9275
Practice Address - Country:US
Practice Address - Phone:270-893-5600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-05
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100872860Medicaid