MEDICARE: MS. IDA B MARR LPP

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	0062	KY
2	103TC0700X	Clinical Psychologist	115837	KY

General Provider Information

NPI Number	:	1437328200
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. IDA B MARR LPP

Provider Business Mailing Address
First Line	:	496 SOUTHLAND DR
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40503-1827
Country	:	US
Telephone Number	:	859-288-2392
Fax Number	:	859-721-2572

Provider Business Practice Location Address
First Line	:	1113 CENTRE PKWY
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40517-3208
Country	:	US
Telephone Number	:	859-288-2425
Fax Number	:	859-721-2572

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

Provider Enumeration Date	:	02/26/2008
Last Update Date	:	09/07/2021

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