=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366772485
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ETERICA DIONNE SIMS-RUCKS LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2010
-----------------------------------------------------
Last Update Date | 10/14/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3113 ABBEY DR SW
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30331-5477
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-423-5900
-----------------------------------------------------
Fax | 866-830-7199
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3485 N DESERT DR # 205
-----------------------------------------------------
City | EAST POINT
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30344-5724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-721-6716
-----------------------------------------------------
Fax | 866-830-7199
-----------------------------------------------------
=====================================================
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 | CSW004169
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------