MEDICARE: MRS. GWENDOLYN ELAINE CHANEY MSW

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	6801071623	MI
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1841444866
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GWENDOLYN ELAINE CHANEY MSW

Provider Business Mailing Address
First Line	:	1969 W BOSTON BLVD
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48206-1728
Country	:	US
Telephone Number	:	313-865-4562
Fax Number	:

Provider Business Practice Location Address
First Line	:	1969 W BOSTON BLVD
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48206-1728
Country	:	US
Telephone Number	:	313-865-4562
Fax Number	:	313-865-9252

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

Provider Enumeration Date	:	11/05/2008
Last Update Date	:	12/10/2009

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