MEDICARE: MS. CONNIE SUE QUALLS BSW

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

General Provider Information

NPI Number	:	1952434961
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CONNIE SUE QUALLS BSW

Provider Business Mailing Address
First Line	:	650 NASHVILLE PIKE STE 7C
Second Line	:
City	:	GALLATIN
State	:	TN
Zip	:	37066-3194
Country	:	US
Telephone Number	:	615-230-9663
Fax Number	:	615-230-8982

Provider Business Practice Location Address
First Line	:	650 NASHVILLE PIKE STE 7C
Second Line	:
City	:	GALLATIN
State	:	TN
Zip	:	37066-3194
Country	:	US
Telephone Number	:	615-230-9663
Fax Number	:	615-230-8982

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

Provider Enumeration Date	:	03/13/2007
Last Update Date	:	07/08/2007

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