MEDICARE: BRETT EDWARD QUANTRILLE LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	4414	LA

General Provider Information

NPI Number	:	1104986272
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRETT EDWARD QUANTRILLE LCSW

Provider Business Mailing Address
First Line	:	16614 APPOMATTOX AVE
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70817-3713
Country	:	US
Telephone Number	:	225-755-5715
Fax Number	:	225-218-4177

Provider Business Practice Location Address
First Line	:	14635 S HARRELLS FERRY RD
Second Line	:	SUITE 6 C
City	:	BATON ROUGE
State	:	LA
Zip	:	70816-2959
Country	:	US
Telephone Number	:	225-755-5715
Fax Number	:	225-218-4177

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	07/27/2009

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