Provider Demographics
NPI:1336179282
Name:QUINN, MARY THERESE (MSW, LISW)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:THERESE
Last Name:QUINN
Suffix:
Gender:F
Credentials:MSW, LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PMS-RRFHC
Mailing Address - Street 2:184 UNSER BOULEVARD
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124
Mailing Address - Country:US
Mailing Address - Phone:505-896-0928
Mailing Address - Fax:
Practice Address - Street 1:PMS-RRFHC
Practice Address - Street 2:184 UNSER BOULEVARD
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124
Practice Address - Country:US
Practice Address - Phone:505-896-0928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-051431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMOTH000Medicare UPIN