1720348188 NPI number — MARCIA C HENNESSEY LCSW

Table of content: MARCIA C HENNESSEY LCSW (NPI 1720348188)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720348188 NPI number — MARCIA C HENNESSEY LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENNESSEY
Provider First Name:
MARCIA
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HENNESSEY
Provider Other First Name:
MARCIA
Provider Other Middle Name:
C
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1720348188
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/09/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
204 PROFESSIONAL CT SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CALHOUN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30701-7020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-625-5900
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 MARKET PLACE BLVD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
CARTERSVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30121-8718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-625-5900
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/20/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  CSW004615 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YA0400X , with the licence number: C0148 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 202I805788 . This is a "MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 003134331C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".