Provider Demographics
NPI:1972199628
Name:QUARLES, DERECK KENDALL
Entity Type:Individual
Prefix:
First Name:DERECK
Middle Name:KENDALL
Last Name:QUARLES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 BATTLECREEK VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-8539
Mailing Address - Country:US
Mailing Address - Phone:404-538-2390
Mailing Address - Fax:
Practice Address - Street 1:2401 BATTLECREEK VILLAGE DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-8539
Practice Address - Country:US
Practice Address - Phone:404-538-2390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-20-146994106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician