MEDICARE: DOUGLAS LEE WELSH

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	103TC0700X	Clinical Psychologist	4981	NC

General Provider Information

NPI Number	:	1093845109
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOUGLAS LEE WELSH

Provider Business Mailing Address
First Line	:	919 N MAIN ST
Second Line	:	SUITE B
City	:	MOORESVILLE
State	:	NC
Zip	:	28115-2355
Country	:	US
Telephone Number	:	704-660-6854
Fax Number	:

Provider Business Practice Location Address
First Line	:	919 N MAIN ST
Second Line	:	SUITE B
City	:	MOORESVILLE
State	:	NC
Zip	:	28115-2355
Country	:	US
Telephone Number	:	704-660-6854
Fax Number	:

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

Provider Enumeration Date	:	03/07/2007
Last Update Date	:	08/01/2017

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