MEDICARE: MS. KAY L GRESHAM LCSW MAC SAP SAE

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	10117	SC
2	1041C0700X	Clinical Social Worker	002457	GA

General Provider Information

NPI Number	:	1366689457
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KAY L GRESHAM LCSW MAC SAP SAE

Provider Business Mailing Address
First Line	:	PO BOX 5664
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30916-5664
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4210 COLUMBIA RD STE 4A
Second Line	:
City	:	MARTINEZ
State	:	GA
Zip	:	30907-0403
Country	:	US
Telephone Number	:	706-993-5186
Fax Number	:

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

Provider Enumeration Date	:	01/12/2009
Last Update Date	:	05/10/2016

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