MEDICARE: MRS. CHERYL AMANDA GRATZ LSW

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	33000009A	IN

General Provider Information

NPI Number	:	1558529933
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CHERYL AMANDA GRATZ LSW

Provider Business Mailing Address
First Line	:	2414 E STATE BLVD
Second Line	:	SUITE 304
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-4760
Country	:	US
Telephone Number	:	260-373-8060
Fax Number	:	260-373-8042

Provider Business Practice Location Address
First Line	:	2414 E STATE BLVD
Second Line	:	SUITE 304
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-4760
Country	:	US
Telephone Number	:	260-373-8060
Fax Number	:	260-373-8042

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

Provider Enumeration Date	:	06/02/2008
Last Update Date	:	06/02/2008

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