Provider Demographics
NPI:1003409640
Name:PERNELL, QUA'SHAWN (BSW, MSW, LCSWA)
Entity Type:Individual
Prefix:
First Name:QUA'SHAWN
Middle Name:
Last Name:PERNELL
Suffix:
Gender:M
Credentials:BSW, MSW, LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 S LINDELL RD APT J
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27403-2096
Mailing Address - Country:US
Mailing Address - Phone:336-457-2989
Mailing Address - Fax:
Practice Address - Street 1:229 TURNER DR
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-5736
Practice Address - Country:US
Practice Address - Phone:336-349-2233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-15
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0149251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical