Healthcare Provider Details

I. General information

NPI: 1114919586
Provider Name (Legal Business Name): MICHAEL PAUL QUIRK PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 12/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1049 CROSS GATE RD
WINSTON SALEM NC
27106-6324
US

IV. Provider business mailing address

1049 CROSS GATE RD
WINSTON SALEM NC
27106-6324
US

V. Phone/Fax

Practice location:
  • Phone: 336-408-4851
  • Fax: 336-408-4851
Mailing address:
  • Phone: 336-408-4851
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2134
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: