MEDICARE: ELIZABETH L EDGE 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	104100000X	Social Worker	MSW003466	GA

General Provider Information

NPI Number	:	1760666473
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH L EDGE LMSW

Provider Business Mailing Address
First Line	:	755 PARK DR NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30306-3681
Country	:	US
Telephone Number	:	404-374-8630
Fax Number	:

Provider Business Practice Location Address
First Line	:	1945 MASON MILL RD STE 100
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30033-4006
Country	:	US
Telephone Number	:	404-374-8630
Fax Number	:

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

Provider Enumeration Date	:	12/18/2007
Last Update Date	:	12/18/2007

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