MEDICARE: THEODRICK HERSEY 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	252541	KY

General Provider Information

NPI Number	:	1740717164
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THEODRICK HERSEY LCSW

Provider Business Mailing Address
First Line	:	501 DARBY CREEK RD STE 7
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40509-1605
Country	:	US
Telephone Number	:	859-227-2337
Fax Number	:	859-268-2472

Provider Business Practice Location Address
First Line	:	501 DARBY CREEK RD STE 7
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40509-1605
Country	:	US
Telephone Number	:	859-227-2337
Fax Number	:	859-268-2472

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

Provider Enumeration Date	:	05/16/2017
Last Update Date	:	05/16/2017

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