Healthcare Provider Details

I. General information

NPI: 1245914720
Provider Name (Legal Business Name): QUIERRA DILWORTH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2023
Last Update Date: 06/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2251 CENTRAL AVE APT B
AUGUSTA GA
30904-6730
US

IV. Provider business mailing address

2251 CENTRAL AVE APT B
AUGUSTA GA
30904-6730
US

V. Phone/Fax

Practice location:
  • Phone: 678-763-0021
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number16773910
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: