MEDICARE: MR. ROGER EARL QUINNEY 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	101YM0800X	Mental Health Counselor	LCS 16707	CA
2	1041C0700X	Clinical Social Worker	SW16707	CA

General Provider Information

NPI Number	:	1740203280
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROGER EARL QUINNEY LCSW

Provider Business Mailing Address
First Line	:	4827 11TH AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90043-4833
Country	:	US
Telephone Number	:	323-292-0801
Fax Number	:

Provider Business Practice Location Address
First Line	:	4602 CRENSHAW BLVD
Second Line	:	SUITE 2C
City	:	LOS ANGELES
State	:	CA
Zip	:	90043-1219
Country	:	US
Telephone Number	:	323-296-1385
Fax Number	:

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

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	04/03/2013

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