MEDICARE: MACON LOSHAWN IRICK 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	104100000X	Social Worker	8523	SC
2	1041C0700X	Clinical Social Worker	CSW004086	GA

General Provider Information

NPI Number	:	1245418763
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MACON LOSHAWN IRICK LCSW

Provider Business Mailing Address
First Line	:	5980 9TH ST
Second Line	:
City	:	FORT BELVOIR
State	:	VA
Zip	:	22060-5509
Country	:	US
Telephone Number	:	706-825-2059
Fax Number	:

Provider Business Practice Location Address
First Line	:	5980 9TH ST BLDG 1259
Second Line	:
City	:	FORT BELVOIR
State	:	VA
Zip	:	22060-5509
Country	:	US
Telephone Number	:	571-231-1210
Fax Number	:	571-231-6808

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

Provider Enumeration Date	:	02/06/2008
Last Update Date	:	07/21/2022

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