MEDICARE: MR. QUASHON ADAIRE JOHNSON SR. 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	7087	OK

General Provider Information

NPI Number	:	1669090130
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. QUASHON ADAIRE JOHNSON SR. LCSW

Provider Business Mailing Address
First Line	:	119 BROOK TRL
Second Line	:
City	:	NEWNAN
State	:	GA
Zip	:	30265-6140
Country	:	US
Telephone Number	:	404-735-1366
Fax Number	:

Provider Business Practice Location Address
First Line	:	6635 BASS RD BLDG 92145
Second Line	:
City	:	FORT BENNING
State	:	GA
Zip	:	31905-5602
Country	:	US
Telephone Number	:	706-257-7205
Fax Number	:	706-626-0827

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

Provider Enumeration Date	:	07/10/2020
Last Update Date	:	07/10/2020

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