MEDICARE: KELLIE H MEDENDORP LSW

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	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1588163158
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLIE H MEDENDORP LSW

Provider Business Mailing Address
First Line	:	1035 VIRGINIA DR STE 130
Second Line	:
City	:	FORT WASHINGTON
State	:	PA
Zip	:	19034-3103
Country	:	US
Telephone Number	:	610-745-4717
Fax Number	:

Provider Business Practice Location Address
First Line	:	1035 VIRGINIA DR STE 130
Second Line	:
City	:	FORT WASHINGTON
State	:	PA
Zip	:	19034-3103
Country	:	US
Telephone Number	:	610-745-4717
Fax Number	:

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

Provider Enumeration Date	:	02/08/2018
Last Update Date	:	02/08/2018

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