MEDICARE: MAKEENA LEE BRICK

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	101YM0800X	Mental Health Counselor		GA

General Provider Information

NPI Number	:	1356944037
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAKEENA LEE BRICK

Provider Business Mailing Address
First Line	:	1593 PIEDMONT AVE NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30324-5241
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1593 PIEDMONT AVE NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30324-5241
Country	:	US
Telephone Number	:	920-794-7260
Fax Number	:

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

Provider Enumeration Date	:	11/17/2020
Last Update Date	:	11/17/2020

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