=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306862966
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MANDY KLEIN LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2006
-----------------------------------------------------
Last Update Date | 09/14/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3205 KIRBY WHITTEN 203 SUITE D
-----------------------------------------------------
City | BARTLETT
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38134-2853
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-430-5009
-----------------------------------------------------
Fax | 901-284-0527
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3030 BRUNSWICK RD
-----------------------------------------------------
City | BARTLETT
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38133-4106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-531-1950
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 2001-C
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 0000006270
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------