Basic Information
| Provider Information | |||||||||
| NPI: | 1760820823 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHASE | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MARTIN | ||||||||
| OtherFirstName: | CARRIE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1351 NEWTOWN PIKE | ||||||||
| Address2: | BLDG 4 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405111275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592531686 | ||||||||
| FaxNumber: | 8599773289 | ||||||||
| Practice Location | |||||||||
| Address1: | 1351 NEWTOWN PIKE | ||||||||
| Address2: | BLDG 4 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405111275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592531686 | ||||||||
| FaxNumber: | 8599773289 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2013 | ||||||||
| LastUpdateDate: | 12/13/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 1790731081 | 05 | KY | MEDICAID |