MEDICARE: LORITA B WHITAKER 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	001106	GA

General Provider Information

NPI Number	:	1184763286
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORITA B WHITAKER LCSW

Provider Business Mailing Address
First Line	:	PO BOX 3175
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30061-3175
Country	:	US
Telephone Number	:	770-426-6460
Fax Number	:	770-919-1456

Provider Business Practice Location Address
First Line	:	77 COLE ST NE
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30060-2030
Country	:	US
Telephone Number	:	770-426-6460
Fax Number	:	770-919-1456

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

Provider Enumeration Date	:	02/05/2007
Last Update Date	:	07/08/2007

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