=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497907174
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLAUDETTE M IDIGO LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2008
-----------------------------------------------------
Last Update Date | 10/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 SAN MARINO CT
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30214-1435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-723-4448
-----------------------------------------------------
Fax | 678-528-2351
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 SAN MARINO CT
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30214-1435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-428-1728
-----------------------------------------------------
Fax | 678-523-2351
-----------------------------------------------------
=====================================================
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 | CSW004018
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------