MEDICARE: MS. GRACE MAE GREENE MSW

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	104100000X	Social Worker	MSW004518	GA

General Provider Information

NPI Number	:	1114291416
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. GRACE MAE GREENE MSW

Provider Business Mailing Address
First Line	:	2751 BUFORD HWY NE STE 202
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30324-5456
Country	:	US
Telephone Number	:	404-325-3113
Fax Number	:	888-973-2726

Provider Business Practice Location Address
First Line	:	2751 BUFORD HWY NE STE 202
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30324-5456
Country	:	US
Telephone Number	:	404-325-3113
Fax Number	:	888-973-2726

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

Provider Enumeration Date	:	03/04/2012
Last Update Date	:	03/04/2012

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