MEDICARE: TEQUILA SEARS 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	1041S0200X	School Social Worker		GA
2	1041C0700X	Clinical Social Worker	CSW009386	GA

General Provider Information

NPI Number	:	1669281994
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TEQUILA SEARS LCSW

Provider Business Mailing Address
First Line	:	3984 LAKE MANOR WAY
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30349-8226
Country	:	US
Telephone Number	:	954-294-4870
Fax Number	:

Provider Business Practice Location Address
First Line	:	3984 LAKE MANOR WAY
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30349-8226
Country	:	US
Telephone Number	:	954-294-4870
Fax Number	:

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

Provider Enumeration Date	:	01/02/2025
Last Update Date	:	01/02/2025

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