Provider Demographics
NPI:1831324664
Name:GRESHAM, QUINTEN G (LCSW)
Entity Type:Individual
Prefix:MR
First Name:QUINTEN
Middle Name:G
Last Name:GRESHAM
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5044 GOLFBROOK DR
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30088-2810
Mailing Address - Country:US
Mailing Address - Phone:770-469-7297
Mailing Address - Fax:770-413-1534
Practice Address - Street 1:5044 GOLFBROOK DR
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30088-2810
Practice Address - Country:US
Practice Address - Phone:770-469-7297
Practice Address - Fax:770-413-1534
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-22
Last Update Date:2009-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0011141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical