MEDICARE: MRS. JEAN MARIE AYERS 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	1041C0700X	Clinical Social Worker	COO4821	NC
2	1041C0700X	Clinical Social Worker	0904004688	VA

General Provider Information

NPI Number	:	1780619007
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JEAN MARIE AYERS LCSW

Provider Business Mailing Address
First Line	:	6817 FAIRVIEW RD STE B
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28210-3598
Country	:	US
Telephone Number	:	704-365-6260
Fax Number	:	704-365-6266

Provider Business Practice Location Address
First Line	:	6817 FAIRVIEW RD STE B
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28210-3598
Country	:	US
Telephone Number	:	704-365-6260
Fax Number	:	704-365-6266

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

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	07/08/2007

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