Provider Demographics
NPI:1144692997
Name:WORTLEY, PATRICIA M (AUD)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:M
Last Name:WORTLEY
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12910 SHELBYVILLE RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40243-1593
Mailing Address - Country:US
Mailing Address - Phone:502-244-2441
Mailing Address - Fax:502-254-4069
Practice Address - Street 1:250 MCDAVID BLVD
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:KY
Practice Address - Zip Code:41143-1603
Practice Address - Country:US
Practice Address - Phone:606-474-7835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-20
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY148705231H00000X
KYSLPAUD00193936231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100411460Medicaid
KY7100411460Medicaid