MEDICARE: MR. WOODFIN JACKSON THRELKELD JR. 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	CSW2002	GA

General Provider Information

NPI Number	:	1831201151
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WOODFIN JACKSON THRELKELD JR. LCSW

Provider Business Mailing Address
First Line	:	2250 N DRUID HILLS RD NE
Second Line	:	SUITE 232
City	:	ATLANTA
State	:	GA
Zip	:	30329-3192
Country	:	US
Telephone Number	:	404-325-3992
Fax Number	:	404-325-5310

Provider Business Practice Location Address
First Line	:	2250 N DRUID HILLS RD NE
Second Line	:	SUITE 232
City	:	ATLANTA
State	:	GA
Zip	:	30329-3192
Country	:	US
Telephone Number	:	404-325-3992
Fax Number	:	404-325-5310

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

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	07/08/2007

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