Healthcare Provider Details

I. General information

NPI: 1376114983
Provider Name (Legal Business Name): MELISSA S CARSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2021
Last Update Date: 07/06/2021
Certification Date: 07/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11103 PARK RD
LOUISVILLE KY
40223-2424
US

IV. Provider business mailing address

10401 LINN STATION RD STE 100
LOUISVILLE KY
40223-3842
US

V. Phone/Fax

Practice location:
  • Phone: 502-245-4171
  • Fax: 502-245-7447
Mailing address:
  • Phone: 502-589-8600
  • Fax: 502-589-8745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number255674
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: