Healthcare Provider Details

I. General information

NPI: 1336179282
Provider Name (Legal Business Name): MARY THERESE QUINN M.S.W., L.I.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 07/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PMS-RRFHC 184 UNSER BOULEVARD
RIO RANCHO NM
87124
US

IV. Provider business mailing address

PMS-RRFHC 184 UNSER BOULEVARD
RIO RANCHO NM
87124
US

V. Phone/Fax

Practice location:
  • Phone: 505-896-0928
  • Fax:
Mailing address:
  • Phone: 505-896-0928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-05143
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: