MEDICARE: LATORJA J O'BRYANT 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	MSW003517	GA
2	1041C0700X	Clinical Social Worker	CSW004597	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326023409
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LATORJA J O'BRYANT LCSW

Provider Business Mailing Address
First Line	:	3523 CRAWFORDVILLE DR
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30909-9437
Country	:	US
Telephone Number	:	706-589-3414
Fax Number	:	706-481-6791

Provider Business Practice Location Address
First Line	:	1 FREEDOM WAY
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30904-6258
Country	:	US
Telephone Number	:	706-733-0188
Fax Number	:

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

Provider Enumeration Date	:	12/12/2005
Last Update Date	:	01/17/2014

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