MEDICARE: MR. GREGORY L MC COLLOUGH 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	1041C0700X	Clinical Social Worker	CSW001591	GA

General Provider Information

NPI Number	:	1376550525
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GREGORY L MC COLLOUGH LCSW

Provider Business Mailing Address
First Line	:	1434 MILL ACRES DR SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30311-3216
Country	:	US
Telephone Number	:	404-730-0230
Fax Number	:

Provider Business Practice Location Address
First Line	:	115 MARTIN LUTHER KING JR DR SW
Second Line	:	SUITE 277
City	:	ATLANTA
State	:	GA
Zip	:	30303-3536
Country	:	US
Telephone Number	:	404-730-0230
Fax Number	:	404-730-0341

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

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	07/08/2007

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