MEDICARE: FQUIRA D JOHANNES LCSWA, LCAS

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	21251	NC
2	1041C0700X	Clinical Social Worker	PO10860	NC

General Provider Information

NPI Number	:	1982942017
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FQUIRA D JOHANNES LCSWA, LCAS

Provider Business Mailing Address
First Line	:	108 BAYBERRY LN
Second Line	:
City	:	GARNER
State	:	NC
Zip	:	27529-4914
Country	:	US
Telephone Number	:	919-210-0883
Fax Number	:

Provider Business Practice Location Address
First Line	:	6500 WILSHIRE BLVD FL 19
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-4920
Country	:	US
Telephone Number	:	800-270-9256
Fax Number	:	805-855-4771

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

Provider Enumeration Date	:	01/24/2013
Last Update Date	:	11/03/2025

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