Provider Demographics
NPI:1760689749
Name:QUATTLEBAUM, SHARIE R (LSCSW)
Entity Type:Individual
Prefix:
First Name:SHARIE
Middle Name:R
Last Name:QUATTLEBAUM
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 467
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67114-0467
Mailing Address - Country:US
Mailing Address - Phone:316-284-6400
Mailing Address - Fax:316-284-6490
Practice Address - Street 1:9333 E 21ST ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-2927
Practice Address - Country:US
Practice Address - Phone:316-634-4703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS40251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200435310AMedicaid