MEDICARE: MR. DAVID JON SACKS LCSW-C

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	12338	MD

General Provider Information

NPI Number	:	1578651394
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAVID JON SACKS LCSW-C

Provider Business Mailing Address
First Line	:	PO BOX 2566
Second Line	:
City	:	PRINCE FREDERICK
State	:	MD
Zip	:	20678-2566
Country	:	US
Telephone Number	:	410-495-8075
Fax Number	:	410-495-8218

Provider Business Practice Location Address
First Line	:	135 W DARES BEACH RD
Second Line	:	SUITE 211
City	:	PRINCE FREDERICK
State	:	MD
Zip	:	20678-3119
Country	:	US
Telephone Number	:	410-495-8075
Fax Number	:	410-495-8218

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

Provider Enumeration Date	:	10/10/2006
Last Update Date	:	07/08/2007

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