MEDICARE: GRETCHEN DERDA WOOSLEY L.C.S.W.

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	C000471	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	141J2	OTHER	NC	BLUE CROSS BLUE SHIELD PR
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225128630
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRETCHEN DERDA WOOSLEY L.C.S.W.

Provider Business Mailing Address
First Line	:	6710 RONDA AVE
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-6125
Country	:	US
Telephone Number	:	704-365-8382
Fax Number	:

Provider Business Practice Location Address
First Line	:	4401 COLWICK RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-2349
Country	:	US
Telephone Number	:	704-365-1113
Fax Number	:	704-365-1757

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

Provider Enumeration Date	:	10/14/2006
Last Update Date	:	07/08/2007

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Directions to “ GRETCHEN DERDA WOOSLEY L.C.S.W.” Practice Location

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