Healthcare Provider Details

I. General information

NPI: 1467108035
Provider Name (Legal Business Name): QILLAWASI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2022
Last Update Date: 02/23/2022
Certification Date: 02/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2043 WEEMS RD. SUITE C2043
TUCKER GA
30084
US

IV. Provider business mailing address

2440 CIRCLEWOOD RD NE
ATLANTA GA
30345-1950
US

V. Phone/Fax

Practice location:
  • Phone: 470-658-9610
  • Fax:
Mailing address:
  • Phone: 470-658-9610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANDRES DARGENT
Title or Position: CEO
Credential:
Phone: 470-658-9610