MEDICARE: MR. CARLO TADEO DOMINGO LMSW

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	MSW004235	GA

General Provider Information

NPI Number	:	1720107188
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CARLO TADEO DOMINGO LMSW

Provider Business Mailing Address
First Line	:	323 WINDMONT DR NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30329-1023
Country	:	US
Telephone Number	:	404-327-8709
Fax Number	:

Provider Business Practice Location Address
First Line	:	1513 CLEVELAND AVE
Second Line	:	BUILDING 300
City	:	EAST POINT
State	:	GA
Zip	:	30344-6947
Country	:	US
Telephone Number	:	404-321-6111
Fax Number	:

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

Provider Enumeration Date	:	03/28/2007
Last Update Date	:	07/08/2007

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