Healthcare Provider Details

I. General information

NPI: 1629357637
Provider Name (Legal Business Name): TED M KIRK SOCIAL WORKER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2011
Last Update Date: 08/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

977A TAYLOR STREET
CONYERS GA
30012
US

IV. Provider business mailing address

977A TAYLOR STREET
CONYERS GA
30012
US

V. Phone/Fax

Practice location:
  • Phone: 770-918-6677
  • Fax: 770-918-6686
Mailing address:
  • Phone: 770-918-6677
  • Fax: 770-918-6686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW004940
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: