Provider Demographics
NPI:1396864088
Name:QUINN, THERESA M (PHD)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:QUINN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:TERRI
Other - Middle Name:M
Other - Last Name:QUINN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:555 CHORRO ST
Mailing Address - Street 2:STE A2
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-2396
Mailing Address - Country:US
Mailing Address - Phone:805-541-0203
Mailing Address - Fax:805-544-7898
Practice Address - Street 1:555 CHORRO ST
Practice Address - Street 2:STE A2
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-2396
Practice Address - Country:US
Practice Address - Phone:805-541-0203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY9673103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY9673OtherBLUE CROSS OF CA PR ID