MEDICARE: SUPPORTED EMPLOYMENT SPECIALISTS

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	251C00000X	Developmentally Disabled Services Day Training Agency

General Provider Information

NPI Number	:	1053473405
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPPORTED EMPLOYMENT SPECIALISTS

Provider Business Mailing Address
First Line	:	615 ROSWELL ST NE
Second Line	:	SUITE 110
City	:	MARIETTA
State	:	GA
Zip	:	30060-2196
Country	:	US
Telephone Number	:	770-499-2172
Fax Number	:	678-354-2670

Provider Business Practice Location Address
First Line	:	615 ROSWELL ST NE
Second Line	:	SUITE 110
City	:	MARIETTA
State	:	GA
Zip	:	30060-2196
Country	:	US
Telephone Number	:	770-499-2172
Fax Number	:	678-354-2670

Authorized Official
Title or Position	:	CEO
Name	:	MRS. DANNA KAYE LONG
Credential	:
Telephone Number	:	770-499-2172

Provider Enumeration Date	:	12/14/2006
Last Update Date	:	08/22/2020

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Directions to “SUPPORTED EMPLOYMENT SPECIALISTS ” Practice Location

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