MEDICARE: CARA DARISE WAISWILOS MS, APC, CRC, NCC

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	101Y00000X	Counselor	APC006616	GA

General Provider Information

NPI Number	:	1720628068
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARA DARISE WAISWILOS MS, APC, CRC, NCC

Provider Business Mailing Address
First Line	:	2120 MARIETTA BLVD NW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30318-2122
Country	:	US
Telephone Number	:	678-365-0071
Fax Number	:	678-365-0098

Provider Business Practice Location Address
First Line	:	2120 MARIETTA BLVD NW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30318-2122
Country	:	US
Telephone Number	:	678-365-0071
Fax Number	:

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

Provider Enumeration Date	:	01/15/2020
Last Update Date	:	01/15/2020

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