Healthcare Provider Details

I. General information

NPI: 1366689457
Provider Name (Legal Business Name): KAY L GRESHAM LCSW MAC SAP SAE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2009
Last Update Date: 05/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4210 COLUMBIA RD STE 4A
MARTINEZ GA
30907-0403
US

IV. Provider business mailing address

PO BOX 5664
AUGUSTA GA
30916-5664
US

V. Phone/Fax

Practice location:
  • Phone: 706-993-5186
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10117
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number002457
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: