Provider Demographics
NPI:1164033783
Name:DORSEY, TANEQUA S (LCSW)
Entity Type:Individual
Prefix:
First Name:TANEQUA
Middle Name:S
Last Name:DORSEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3605 TINSLEY WAY SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-5465
Mailing Address - Country:US
Mailing Address - Phone:404-697-7360
Mailing Address - Fax:
Practice Address - Street 1:40 MACON STREET
Practice Address - Street 2:SUITE D
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253
Practice Address - Country:US
Practice Address - Phone:678-831-7377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW006924101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health