=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003303231
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BONITA JO KLOPACH MSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2018
-----------------------------------------------------
Last Update Date | 04/13/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4343 SHALLOWFORD RD STE C-1
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30062-5023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-740-3757
-----------------------------------------------------
Fax | 770-993-9800
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4343 SHALLOWFORD RD STE C-1
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30062-5023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-740-3757
-----------------------------------------------------
Fax | 770-993-9800
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | MSW006828
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------