MEDICARE: DR. TRACI GANAWAY LCSW-C

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	12178	MD
2	1041C0700X	Clinical Social Worker	LC50078136	DC

General Provider Information

NPI Number	:	1881920916
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TRACI GANAWAY LCSW-C

Provider Business Mailing Address
First Line	:	9543 TESSA LN
Second Line	:
City	:	OWINGS MILLS
State	:	MD
Zip	:	21117-3276
Country	:	US
Telephone Number	:	410-493-9411
Fax Number	:	410-356-1583

Provider Business Practice Location Address
First Line	:	9543 TESSA LN
Second Line	:
City	:	OWINGS MILLS
State	:	MD
Zip	:	21117-3276
Country	:	US
Telephone Number	:	410-493-9411
Fax Number	:	410-356-1583

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

Provider Enumeration Date	:	10/23/2009
Last Update Date	:	05/08/2013

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