MEDICARE: MS. MATILDA JULIET DINKINS CRC

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	225C00000X	Rehabilitation Counselor	642775	GA

General Provider Information

NPI Number	:	1417737768
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MATILDA JULIET DINKINS CRC

Provider Business Mailing Address
First Line	:	2260 MOUNT CARMEL RD
Second Line	:
City	:	HAMPTON
State	:	GA
Zip	:	30228-2841
Country	:	US
Telephone Number	:	404-281-8506
Fax Number	:

Provider Business Practice Location Address
First Line	:	2260 MOUNT CARMEL RD
Second Line	:
City	:	HAMPTON
State	:	GA
Zip	:	30228-2841
Country	:	US
Telephone Number	:	404-281-8506
Fax Number	:

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

Provider Enumeration Date	:	10/04/2023
Last Update Date	:	10/04/2023

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