Provider Demographics
NPI:1124287115
Name:BADGETT, TINA
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:BADGETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 BLUE BIRD LN
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:KY
Mailing Address - Zip Code:41143-8726
Mailing Address - Country:US
Mailing Address - Phone:606-475-1912
Mailing Address - Fax:
Practice Address - Street 1:149 BLUE BIRD LN
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:KY
Practice Address - Zip Code:41143-8726
Practice Address - Country:US
Practice Address - Phone:606-475-1912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-04
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist