=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780414458
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE DARLENE WAFORD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2024
-----------------------------------------------------
Last Update Date | 08/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 RODEO DR
-----------------------------------------------------
City | ERLANGER
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41018-1279
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-594-1434
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 80 TRIPLE D DR
-----------------------------------------------------
City | TAYLORSVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40071-9222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-594-1434
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------