MEDICARE: KELSIE TIEMAN OVERBEY 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	P007451	NC

General Provider Information

NPI Number	:	1265860043
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELSIE TIEMAN OVERBEY LCSWA

Provider Business Mailing Address
First Line	:	4805 GREEN RD STE 103
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27616-2848
Country	:	US
Telephone Number	:	660-815-5977
Fax Number	:

Provider Business Practice Location Address
First Line	:	4805 GREEN RD STE 103
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27616-2848
Country	:	US
Telephone Number	:	660-815-5977
Fax Number	:

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

Provider Enumeration Date	:	10/15/2013
Last Update Date	:	10/15/2013

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