MEDICARE: BRANDON TWEEDY ICADC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	1280	GA
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	E088	GA
3	101YA0400X	Addiction (Substance Use Disorder) Counselor	173834	GA

General Provider Information

NPI Number	:	1649734955
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDON TWEEDY ICADC

Provider Business Mailing Address
First Line	:	400 W PEACHTREE ST NW UNIT 1116
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30308-3547
Country	:	US
Telephone Number	:	757-746-3812
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 W PEACHTREE ST NW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30308-3536
Country	:	US
Telephone Number	:	757-746-3812
Fax Number	:

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

Provider Enumeration Date	:	01/31/2019
Last Update Date	:	01/31/2019

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