Healthcare Provider Details

I. General information

NPI: 1740622802
Provider Name (Legal Business Name): CYNTHIA QUINTANA-MONTENEGRO LLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2013
Last Update Date: 07/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 LEONARD ST NE
GRAND RAPIDS MI
49505-5515
US

IV. Provider business mailing address

1952 CLEVELAND AVE SW
WYOMING MI
49509-1455
US

V. Phone/Fax

Practice location:
  • Phone: 616-954-1992
  • Fax:
Mailing address:
  • Phone: 616-430-2968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801095665
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: