=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548758899
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY MADEWELL LISW-S
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2018
-----------------------------------------------------
Last Update Date | 10/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 85 S MAY AVE
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45701-2016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-593-7125
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1158
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45701-1158
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | I1101146
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------