Provider Demographics
NPI:1366145195
Name:VARGHESE, JOANNA SHEFALI
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:SHEFALI
Last Name:VARGHESE
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 1:776 MIMOSA WAY
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:GA
Mailing Address - Zip Code:30549-5464
Mailing Address - Country:US
Mailing Address - Phone:706-296-4191
Mailing Address - Fax:
Practice Address - Street 1:776 MIMOSA WAY
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:GA
Practice Address - Zip Code:30549-5464
Practice Address - Country:US
Practice Address - Phone:706-296-4191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-22
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-23-264273106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician