MEDICARE: MRS. TAMARA MANIS PERCIFUL L.C.S.W.

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	#CSW002745	GA

General Provider Information

NPI Number	:	1124260419
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TAMARA MANIS PERCIFUL L.C.S.W.

Provider Business Mailing Address
First Line	:	4167 ROSWELL ROAD, NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30342
Country	:	US
Telephone Number	:	404-252-5055
Fax Number	:	404-252-5589

Provider Business Practice Location Address
First Line	:	4167 ROSWELL ROAD, NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30342
Country	:	US
Telephone Number	:	404-252-5055
Fax Number	:	404-252-5589

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

Provider Enumeration Date	:	04/01/2009
Last Update Date	:	04/01/2009

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