Healthcare Provider Details

I. General information

NPI: 1093005795
Provider Name (Legal Business Name): LESLIE JEAN QUACKENBUSH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2011
Last Update Date: 01/10/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 STEVE REYNOLDS BLVD GWINNETT COMPREHENSIVE MEDICAL CENTER
DULUTH GA
30096-4506
US

IV. Provider business mailing address

3495 PIEDMONT RD NE NINE PIEDMONT CENTER
ATLANTA GA
30305-1717
US

V. Phone/Fax

Practice location:
  • Phone: 919-764-2000
  • Fax:
Mailing address:
  • Phone: 404-504-5678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP004774
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW005307
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: