=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992299648
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | QUICHA STRONG LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2018
-----------------------------------------------------
Last Update Date | 06/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 175 GWINNETT DR
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30046-8444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-209-2394
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2700 PARKWAY TRL
-----------------------------------------------------
City | LITHONIA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30058-4647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-402-4461
-----------------------------------------------------
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 | MSW007667
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------