MEDICARE: EBONY NICOLE CALLOWAY LICSW

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	SW12357	FL
2	1041C0700X	Clinical Social Worker	LC50080428	DC
3	1041C0700X	Clinical Social Worker	0904010339	VA

General Provider Information

NPI Number	:	1467987974
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EBONY NICOLE CALLOWAY LICSW

Provider Business Mailing Address
First Line	:	16712 JEFFERSON DAVIS HWY
Second Line	:
City	:	DUMFRIES
State	:	VA
Zip	:	22026-2115
Country	:	US
Telephone Number	:	703-221-7467
Fax Number	:	703-221-4115

Provider Business Practice Location Address
First Line	:	16712 JEFFERSON DAVIS HWY
Second Line	:
City	:	DUMFRIES
State	:	VA
Zip	:	22026-2115
Country	:	US
Telephone Number	:	703-221-7467
Fax Number	:	703-221-4115

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

Provider Enumeration Date	:	04/22/2017
Last Update Date	:	03/14/2024

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