MEDICARE: MS. KRISTEN MCCLURE 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	C003294	NC

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	138UP	OTHER	NC	BLUECROSSBLUESHIELD

General Provider Information

NPI Number	:	1891749651
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KRISTEN MCCLURE LCSW

Provider Business Mailing Address
First Line	:	1515 MOCKINGBIRD LN
Second Line	:	SUITE 814
City	:	CHARLOTTE
State	:	NC
Zip	:	28209-3236
Country	:	US
Telephone Number	:	704-525-8787
Fax Number	:	704-525-8789

Provider Business Practice Location Address
First Line	:	1515 MOCKINGBIRD LN
Second Line	:	SUITE 814
City	:	CHARLOTTE
State	:	NC
Zip	:	28209-3236
Country	:	US
Telephone Number	:	704-525-8787
Fax Number	:	704-525-8789

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

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	07/08/2007

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