Healthcare Provider Details

I. General information

NPI: 1316731219
Provider Name (Legal Business Name): ELIZABETH M QUINTAVALLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2025
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2808 ENTERPRISE RD STE 105
DEBARY FL
32713-2753
US

IV. Provider business mailing address

2808 ENTERPRISE RD STE 105
DEBARY FL
32713-2753
US

V. Phone/Fax

Practice location:
  • Phone: 386-259-5413
  • Fax:
Mailing address:
  • Phone: 386-259-5413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SL05362800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: