MEDICARE: TITERRIELL MACKLIN

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	283528	KY

General Provider Information

NPI Number	:	1669654943
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TITERRIELL MACKLIN

Provider Business Mailing Address
First Line	:	7528 AVALON SPRINGS DR
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40228-2588
Country	:	US
Telephone Number	:	502-386-8638
Fax Number	:

Provider Business Practice Location Address
First Line	:	7528 AVALON SPRINGS DR
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40228-2588
Country	:	US
Telephone Number	:	502-386-8638
Fax Number	:

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

Provider Enumeration Date	:	11/29/2007
Last Update Date	:	09/24/2024

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