=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245866573
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MONICA TATE LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2020
-----------------------------------------------------
Last Update Date | 07/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 165 DEKALB INDUSTRIAL WAY STE D-1
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30030-2230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-775-7618
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 166 HILLCREST CIR
-----------------------------------------------------
City | HIRAM
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30141-5256
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | CSW008631
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------