Provider Demographics
NPI:1083709976
Name:MEDLEY, CHARLES DAVID (LCSW)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DAVID
Last Name:MEDLEY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3150 CUSTER DR.
Mailing Address - Street 2:SUITE203
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517
Mailing Address - Country:US
Mailing Address - Phone:859-271-7788
Mailing Address - Fax:859-273-3306
Practice Address - Street 1:3150 CUSTER DR.
Practice Address - Street 2:SUITE203
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40517
Practice Address - Country:US
Practice Address - Phone:859-271-7788
Practice Address - Fax:859-273-3306
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical