Provider Demographics
NPI:1477768604
Name:FEDERMAN, ILENE BABS (MSSW)
Entity Type:Individual
Prefix:MISS
First Name:ILENE
Middle Name:BABS
Last Name:FEDERMAN
Suffix:
Gender:F
Credentials:MSSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7402 SAINT CHARLES SQ
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-3873
Mailing Address - Country:US
Mailing Address - Phone:770-552-4018
Mailing Address - Fax:
Practice Address - Street 1:242 CREEKSTONE RDG
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-3732
Practice Address - Country:US
Practice Address - Phone:678-445-4184
Practice Address - Fax:678-445-5146
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0014541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical