MEDICARE: MRS. NICOLE LALLY LCSW TCADC

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	7016	KY

General Provider Information

NPI Number	:	1598246043
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NICOLE LALLY LCSW TCADC

Provider Business Mailing Address
First Line	:	961 BEASLEY ST STE 170
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40509-4120
Country	:	US
Telephone Number	:	859-382-7328
Fax Number	:	859-286-6448

Provider Business Practice Location Address
First Line	:	961 BEASLEY ST STE 170
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40509-4120
Country	:	US
Telephone Number	:	859-382-7328
Fax Number	:	859-286-6448

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

Provider Enumeration Date	:	08/23/2018
Last Update Date	:	08/23/2018

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