MEDICARE: KELLY STEPHENS

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

General Provider Information

NPI Number	:	1770943060
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY STEPHENS

Provider Business Mailing Address
First Line	:	194 FOUNTAIN LAKE DR S
Second Line	:
City	:	SHELBYVILLE
State	:	IN
Zip	:	46176-9780
Country	:	US
Telephone Number	:	317-604-6924
Fax Number	:

Provider Business Practice Location Address
First Line	:	194 FOUNTAIN LAKE DR S
Second Line	:
City	:	SHELBYVILLE
State	:	IN
Zip	:	46176-9780
Country	:	US
Telephone Number	:	317-604-6924
Fax Number	:

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

Provider Enumeration Date	:	02/29/2016
Last Update Date	:	02/29/2016

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Directions to “ KELLY STEPHENS ” Practice Location

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