MEDICARE: MRS. CARLA DENISE MCGOWAN 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	C5523	MS

General Provider Information

NPI Number	:	1114467495
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CARLA DENISE MCGOWAN LCSW

Provider Business Mailing Address
First Line	:	3048 BIENVILLE DR
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39212-2540
Country	:	US
Telephone Number	:	601-946-3256
Fax Number	:

Provider Business Practice Location Address
First Line	:	3048 BIENVILLE DR
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39212-2540
Country	:	US
Telephone Number	:	601-946-3256
Fax Number	:

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

Provider Enumeration Date	:	03/06/2017
Last Update Date	:	03/06/2017

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