=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437499241
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMUEL H STODGHILL PSY.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2013
-----------------------------------------------------
Last Update Date | 02/15/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8143 NEW LAGRANGE ROAD
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-632-2471
-----------------------------------------------------
Fax | 502-690-3731
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 STILZ AVE
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40206-2622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-810-4515
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 1447
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------