Provider Demographics
NPI:1659192219
Name:ANDERSON, SHERQUON QUATAVIS
Entity type:Individual
Prefix:
First Name:SHERQUON
Middle Name:QUATAVIS
Last Name:ANDERSON
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 1:801 HIGHWAY 70 W TRLR 3
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-7625
Mailing Address - Country:US
Mailing Address - Phone:478-867-9697
Mailing Address - Fax:
Practice Address - Street 1:131 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:HAWKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31036-4617
Practice Address - Country:US
Practice Address - Phone:478-867-9697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-17
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA058640864103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst