Provider Demographics
NPI:1467209437
Name:BREW-CHANN, TEQUILLA
Entity type:Individual
Prefix:
First Name:TEQUILLA
Middle Name:
Last Name:BREW-CHANN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 W 40TH ST UNIT 2225
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37409-1379
Mailing Address - Country:US
Mailing Address - Phone:877-358-2998
Mailing Address - Fax:
Practice Address - Street 1:75 WALKER INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:RINGGOLD
Practice Address - State:GA
Practice Address - Zip Code:30736-7581
Practice Address - Country:US
Practice Address - Phone:877-358-2998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-06
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW610142041041C0700X
TX1035781041C0700X
CALCSW950361041C0700X
GACSW0087171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical