MEDICARE: MRS. MICHELLE ANN DATTADA MSW, 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	104100000X	Social Worker	P004806	NC
2	104100000X	Social Worker	33SL05490100	NJ

General Provider Information

NPI Number	:	1275773749
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MICHELLE ANN DATTADA MSW, LCSW

Provider Business Mailing Address
First Line	:	5878 FARINGDON PL
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27609-4589
Country	:	US
Telephone Number	:	919-872-4833
Fax Number	:

Provider Business Practice Location Address
First Line	:	5878 FARINGDON PL
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27609-4589
Country	:	US
Telephone Number	:	919-872-4833
Fax Number	:

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

Provider Enumeration Date	:	02/24/2009
Last Update Date	:	11/18/2010

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