MEDICARE: ELISE ANTROBUS LCSW

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	00003434	GA

General Provider Information

NPI Number	:	1093358962
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELISE ANTROBUS LCSW

Provider Business Mailing Address
First Line	:	1772 CHASEWOOD PARK LN
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30066-4296
Country	:	US
Telephone Number	:	404-402-2261
Fax Number	:

Provider Business Practice Location Address
First Line	:	707 WHITLOCK AVE SW STE C28
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30064-4655
Country	:	US
Telephone Number	:	404-402-2261
Fax Number	:

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

Provider Enumeration Date	:	10/23/2019
Last Update Date	:	10/23/2019

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