MEDICARE: MADISON SHAE MULLIN

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	104100000X	Social Worker	MSW010296	GA

General Provider Information

NPI Number	:	1053064295
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADISON SHAE MULLIN

Provider Business Mailing Address
First Line	:	4364 MILFORD PL
Second Line	:
City	:	HOSCHTON
State	:	GA
Zip	:	30548-1674
Country	:	US
Telephone Number	:	502-370-7532
Fax Number	:

Provider Business Practice Location Address
First Line	:	1093 CLEVELAND AVE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30344-6740
Country	:	US
Telephone Number	:	404-768-2218
Fax Number	:

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

Provider Enumeration Date	:	01/28/2022
Last Update Date	:	01/28/2022

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