MEDICARE: MRS. MICHELLE MARLEY FENLEY MSW 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	0904005990	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	181498	OTHER	VA	BLUE CROSS

General Provider Information

NPI Number	:	1154356640
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MICHELLE MARLEY FENLEY MSW LCSW

Provider Business Mailing Address
First Line	:	260 GRAYSON ROAD
Second Line	:	JEWISH FAMILY SERVICE OF TIDEWATER INC
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-4345
Country	:	US
Telephone Number	:	757-459-4640
Fax Number	:	757-459-4643

Provider Business Practice Location Address
First Line	:	260 GRAYSON ROAD
Second Line	:	JEWISH FAMILY SERVICE OF TIDEWATER INC
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-4345
Country	:	US
Telephone Number	:	757-459-4640
Fax Number	:	757-459-4643

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

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	07/09/2007

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