Provider Demographics
NPI:1104641216
Name:QUINTEROS, STEPHANIE ALEXA
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ALEXA
Last Name:QUINTEROS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 FOREST LN
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-3244
Mailing Address - Country:US
Mailing Address - Phone:510-230-7466
Mailing Address - Fax:
Practice Address - Street 1:75 FOREST LN
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-3244
Practice Address - Country:US
Practice Address - Phone:510-230-7466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-22
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician