MEDICARE: KELLY CAMARATA M.ED, LPC,CAADC, SA

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	101YP2500X	Professional Counselor	LPC008262	GA
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	C0168	GA

General Provider Information

NPI Number	:	1578900122
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY CAMARATA M.ED, LPC,CAADC, SA

Provider Business Mailing Address
First Line	:	201 MARGIE CT
Second Line	:
City	:	MCDONOUGH
State	:	GA
Zip	:	30252-3105
Country	:	US
Telephone Number	:	404-277-3747
Fax Number	:

Provider Business Practice Location Address
First Line	:	35 ATLANTA ST
Second Line	:	SUITE #5-B
City	:	MCDONOUGH
State	:	GA
Zip	:	30253-2162
Country	:	US
Telephone Number	:	678-758-5578
Fax Number	:

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

Provider Enumeration Date	:	05/22/2013
Last Update Date	:	08/12/2016

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