MEDICARE: MR. ROBERT DENNIS JR.

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	101YP1600X	Pastoral Counselor

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
2	84-1880551	OTHER	GA	IRS

General Provider Information

NPI Number	:	1376100321
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERT DENNIS JR.

Provider Business Mailing Address
First Line	:	608 HARDEMAN AVE
Second Line	:
City	:	FORT VALLEY
State	:	GA
Zip	:	31030-3438
Country	:	US
Telephone Number	:	478-957-8447
Fax Number	:

Provider Business Practice Location Address
First Line	:	608 HARDEMAN AVE
Second Line	:
City	:	FORT VALLEY
State	:	GA
Zip	:	31030-3438
Country	:	US
Telephone Number	:	478-957-8447
Fax Number	:

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

Provider Enumeration Date	:	05/24/2019
Last Update Date	:	05/24/2019

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