Healthcare Provider Details

I. General information

NPI: 1942856265
Provider Name (Legal Business Name): AUTUMN L QUIROZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2019
Last Update Date: 12/02/2019
Certification Date:
Deactivation Date: 09/23/2019
Reactivation Date: 09/30/2019

III. Provider practice location address

1601 E 4TH BLVD
VANCOUVER WA
98661
US

IV. Provider business mailing address

211 SE 89TH AVE
PORTLAND OR
97216-1539
US

V. Phone/Fax

Practice location:
  • Phone: 360-397-8246
  • Fax:
Mailing address:
  • Phone: 971-202-6431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: