=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013757574
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIARA STREET LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2024
-----------------------------------------------------
Last Update Date | 05/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 250 GEORGIA AVE SE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30312-3046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-377-5990
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1164 MISTY MEADOWS WAY
-----------------------------------------------------
City | HAMPTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30228-6154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-425-0195
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | MSW011882
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------