Provider Demographics
NPI:1699124594
Name:COMMONWEALTH OF KENTUCKY
Entity type:Organization
Organization Name:COMMONWEALTH OF KENTUCKY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CAO
Authorized Official - Prefix:
Authorized Official - First Name:TANYIKA
Authorized Official - Middle Name:R
Authorized Official - Last Name:WAN
Authorized Official - Suffix:
Authorized Official - Credentials:RHIT
Authorized Official - Phone:502-368-2348
Mailing Address - Street 1:4501 LOUISE UNDERWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40216-3987
Mailing Address - Country:US
Mailing Address - Phone:502-368-2348
Mailing Address - Fax:502-371-9067
Practice Address - Street 1:4501 LOUISE UNDERWOOD WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-3987
Practice Address - Country:US
Practice Address - Phone:502-368-2348
Practice Address - Fax:502-371-9067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-10
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYSLPINP00225532235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty