Provider Demographics
NPI:1164932190
Name:QUACKENBUSH, MEGAN (LCSW-A)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:QUACKENBUSH
Suffix:
Gender:F
Credentials:LCSW-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9908 HOLLY CENTER DR APT 307
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-5118
Mailing Address - Country:US
Mailing Address - Phone:704-621-9189
Mailing Address - Fax:
Practice Address - Street 1:134 INFIELD CT
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117
Practice Address - Country:US
Practice Address - Phone:704-799-6824
Practice Address - Fax:704-799-6825
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0120171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical