=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376765388
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AZAM MOLOOK SHEIRLING LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 139 HENRY PARKWAY HENRY COUNTY COUNSELING CENTER
-----------------------------------------------------
City | MCDONOUGH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-898-7421
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 145 PRICE DRIVE WEST
-----------------------------------------------------
City | LOCUST GROVE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-914-2169
-----------------------------------------------------
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 | CSW001086
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------