=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184196560
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAKEISHA QUINTA ROBINSON LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2018
-----------------------------------------------------
Last Update Date | 12/21/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2795 MAIN ST W BLDG 20
-----------------------------------------------------
City | SNELLVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30078-3164
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-798-6847
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6285 SUNFLOWER PL
-----------------------------------------------------
City | LITHONIA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30038-6211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-798-6847
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | MSW006915
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------