=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366454100
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOSHE MARVIN E GITTELSON LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 250 ARROWHEAD BLVD
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30236-1106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-617-2469
-----------------------------------------------------
Fax | 770-603-3063
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 289 ROBIN HOOD RD NE NORTHEAST
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30309-2635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-617-2469
-----------------------------------------------------
Fax | 770-603-3063
-----------------------------------------------------
=====================================================
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 | 001061
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------