MEDICARE: ADELMAR DE LOS ANGELES WINNER 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	C008026	NC

General Provider Information

NPI Number	:	1033455506
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ADELMAR DE LOS ANGELES WINNER LCSW

Provider Business Mailing Address
First Line	:	3801 LAKE BOONE TRL STE 100
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27607-2994
Country	:	US
Telephone Number	:	919-865-8788
Fax Number	:

Provider Business Practice Location Address
First Line	:	3801 LAKE BOONE TRL STE 100
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27607-2994
Country	:	US
Telephone Number	:	919-865-8788
Fax Number	:

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

Provider Enumeration Date	:	01/02/2013
Last Update Date	:	01/02/2013

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