MEDICARE: BETTY ALEXANDRA KEDROCK LCSW

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	1041C0700X	Clinical Social Worker	0904000234	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	A163599	OTHER		VALUE OPTIONS
3	080436	OTHER	VA	OPTIMA
4	324004	OTHER		MANAGED HEALTH NETWORK
5	247697	OTHER		COM PSYCH
6	049958	OTHER	VA	BLUE CROSS BLUE SHIELD
7	216188	OTHER	VA	UCH
8	5264256	OTHER	VA	AETNA
9	028883	OTHER	VA	VALUE OPTION

General Provider Information

NPI Number	:	1275533796
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETTY ALEXANDRA KEDROCK LCSW

Provider Business Mailing Address
First Line	:	1709 COLLEY AVE
Second Line	:	SUITE 312
City	:	NORFOLK
State	:	VA
Zip	:	23517-1675
Country	:	US
Telephone Number	:	757-640-0400
Fax Number	:	757-640-0497

Provider Business Practice Location Address
First Line	:	1709 COLLEY AVE
Second Line	:	SUITE 312
City	:	NORFOLK
State	:	VA
Zip	:	23517-1675
Country	:	US
Telephone Number	:	757-640-0400
Fax Number	:	757-640-0497

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

Provider Enumeration Date	:	07/27/2005
Last Update Date	:	07/08/2007

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Directions to “ BETTY ALEXANDRA KEDROCK LCSW” Practice Location

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