MEDICARE: COLIN DOUGLAS QUENNELL LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	MFC32602	CA

General Provider Information

NPI Number	:	1376759126
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLIN DOUGLAS QUENNELL LMFT

Provider Business Mailing Address
First Line	:	1040 ZINNIA CT
Second Line	:
City	:	NIPOMO
State	:	CA
Zip	:	93444-9647
Country	:	US
Telephone Number	:	805-929-6532
Fax Number	:

Provider Business Practice Location Address
First Line	:	1106 E GRAND AVE
Second Line	:
City	:	ARROYO GRANDE
State	:	CA
Zip	:	93420-2516
Country	:	US
Telephone Number	:	805-473-7080
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/15/2007
Last Update Date	:	07/08/2007

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