MEDICARE: KEVIN GRANT FACKLER TSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	99114992A	IN

General Provider Information

NPI Number	:	1275242869
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN GRANT FACKLER TSW

Provider Business Mailing Address
First Line	:	4922 LAGOONA DR
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40219-5404
Country	:	US
Telephone Number	:	502-396-2358
Fax Number	:

Provider Business Practice Location Address
First Line	:	4922 LAGOONA DR
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40219-5404
Country	:	US
Telephone Number	:	502-396-2358
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/22/2022
Last Update Date	:	09/25/2023

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