MEDICARE: CHARLES DAVID MEDLEY LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	144	KY

General Provider Information

NPI Number	:	1083709976
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES DAVID MEDLEY LCSW

Provider Business Mailing Address
First Line	:	3150 CUSTER DR.
Second Line	:	SUITE203
City	:	LEXINGTON
State	:	KY
Zip	:	40517
Country	:	US
Telephone Number	:	859-271-7788
Fax Number	:	859-273-3306

Provider Business Practice Location Address
First Line	:	3150 CUSTER DR.
Second Line	:	SUITE203
City	:	LEXINGTON
State	:	KY
Zip	:	40517
Country	:	US
Telephone Number	:	859-271-7788
Fax Number	:	859-273-3306

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	07/08/2007

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