MEDICARE: MS. CARMELLIA THOMAS BUMGARDNER LCSW

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	C004066	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770633679
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CARMELLIA THOMAS BUMGARDNER LCSW

Provider Business Mailing Address
First Line	:	284 EXECUTIVE PARK DRIVE
Second Line	:	STE 100
City	:	CONCORD
State	:	NC
Zip	:	28025-1833
Country	:	US
Telephone Number	:	704-939-1100
Fax Number	:	704-939-1173

Provider Business Practice Location Address
First Line	:	351 RIVERSIDE DR
Second Line	:
City	:	MOUNT AIRY
State	:	NC
Zip	:	27030-3850
Country	:	US
Telephone Number	:	336-786-7079
Fax Number	:	336-786-6312

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

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	05/26/2017

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