=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396902573
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMBRACE INNOVATIONS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2008
-----------------------------------------------------
Last Update Date | 05/16/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5555 GLENRDG CONN NE SUITE 200
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30342-4759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-873-4742
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 82 GOLDRUSH CIR NE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30328-5245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | KIMBERLY ROBERSON
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 404-843-4742
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | CSW003926
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------