MEDICARE: DEADRA CARNACK ATKINS LCSW-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	4752	MD

General Provider Information

NPI Number	:	1033237771
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEADRA CARNACK ATKINS LCSW-C

Provider Business Mailing Address
First Line	:	6936 KNIGHTHOOD LN
Second Line	:
City	:	COLUMBIA
State	:	MD
Zip	:	21045-4801
Country	:	US
Telephone Number	:	410-381-0559
Fax Number	:

Provider Business Practice Location Address
First Line	:	122 LANGLEY RD N
Second Line	:	SUITE A
City	:	GLEN BURNIE
State	:	MD
Zip	:	21060-6539
Country	:	US
Telephone Number	:	410-222-6785
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/27/2007
Last Update Date	:	07/08/2007

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