Basic Information
| Provider Information | |||||||||
| NPI: | 1154558930 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FLETCHER | ||||||||
| FirstName: | CARLA | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | DODD | ||||||||
| OtherFirstName: | CARLA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 101 W MUHAMMAD ALI BLVD | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025896000 | ||||||||
| FaxNumber: | 5035898771 | ||||||||
| Practice Location | |||||||||
| Address1: | 2225 W BROADWAY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402111003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025898600 | ||||||||
| FaxNumber: | 5025898771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2009 | ||||||||
| LastUpdateDate: | 01/13/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 1041C0700X | 3793 | KY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.