MEDICARE: TAMARA LEE CONLIN 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	CSW003718	GA
2	1041C0700X	Clinical Social Worker	077007	NY

General Provider Information

NPI Number	:	1639234917
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMARA LEE CONLIN LCSW

Provider Business Mailing Address
First Line	:	6247 KNAPP RD
Second Line	:
City	:	CANANDAIGUA
State	:	NY
Zip	:	14424-8932
Country	:	US
Telephone Number	:	585-208-5647
Fax Number	:

Provider Business Practice Location Address
First Line	:	175 GWINNETT DR
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30046-8444
Country	:	US
Telephone Number	:	770-339-5301
Fax Number	:

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

Provider Enumeration Date	:	12/27/2006
Last Update Date	:	08/22/2011

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