MEDICARE: KECIA THOMPSON RUTLEDGE LCSWA

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	P020073	NC

General Provider Information

NPI Number	:	1144090135
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KECIA THOMPSON RUTLEDGE LCSWA

Provider Business Mailing Address
First Line	:	4440 MERLANE DR APT 108
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28213-6081
Country	:	US
Telephone Number	:	704-967-9393
Fax Number	:

Provider Business Practice Location Address
First Line	:	4440 MERLANE DR APT 108
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28213-6081
Country	:	US
Telephone Number	:	704-967-9393
Fax Number	:

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

Provider Enumeration Date	:	01/02/2024
Last Update Date	:	01/02/2024

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