MEDICARE: SENTORIA GREEN 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	MSW012403	GA

General Provider Information

NPI Number	:	1760283840
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SENTORIA GREEN LMSW

Provider Business Mailing Address
First Line	:	956 GRAHAM CAMPBELL LN
Second Line	:
City	:	STATHAM
State	:	GA
Zip	:	30666-1896
Country	:	US
Telephone Number	:	706-410-0616
Fax Number	:

Provider Business Practice Location Address
First Line	:	1691 MERIWEATHER DR STE 109
Second Line	:
City	:	WATKINSVILLE
State	:	GA
Zip	:	30677-7787
Country	:	US
Telephone Number	:	706-883-5300
Fax Number	:

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

Provider Enumeration Date	:	03/24/2025
Last Update Date	:	03/24/2025

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