MEDICARE: WILLIE WALTER WHITED 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	002541	GA

General Provider Information

NPI Number	:	1568493906
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIE WALTER WHITED LCSW

Provider Business Mailing Address
First Line	:	1650 ADAMS DR SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30311-3626
Country	:	US
Telephone Number	:	404-344-3552
Fax Number	:	404-344-4275

Provider Business Practice Location Address
First Line	:	1650 ADAMS DR SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30311-3626
Country	:	US
Telephone Number	:	678-772-5677
Fax Number	:	404-344-4275

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

Provider Enumeration Date	:	07/05/2006
Last Update Date	:	04/19/2017

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