Healthcare Provider Details

I. General information

NPI: 1669281994
Provider Name (Legal Business Name): TEQUILA SEARS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2025
Last Update Date: 01/02/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3984 LAKE MANOR WAY
ATLANTA GA
30349-8226
US

IV. Provider business mailing address

3984 LAKE MANOR WAY
ATLANTA GA
30349-8226
US

V. Phone/Fax

Practice location:
  • Phone: 954-294-4870
  • Fax:
Mailing address:
  • Phone: 954-294-4870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW009386
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: