=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639397474
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY H. TEVEBAUGH LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3950 KRESGE WAY
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40207-4637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-896-7132
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1822 KNOLLWOOD RD
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40207-1767
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-896-7124
-----------------------------------------------------
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 | LCSW-1408
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------