Healthcare Provider Details

I. General information

NPI: 1114322120
Provider Name (Legal Business Name): SANDRA MEDLEY PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2014
Last Update Date: 11/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2441 S HIGHWAY 27
SOMERSET KY
42501-2935
US

IV. Provider business mailing address

2441 S HIGHWAY 27
SOMERSET KY
42501-2935
US

V. Phone/Fax

Practice location:
  • Phone: 606-219-2755
  • Fax:
Mailing address:
  • Phone: 606-219-2755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberKY-1246
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberKY-1246
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberKY-1246
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License NumberKY-1246
License Number StateKY
# 5
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License NumberKY-1246
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: