Provider Demographics
NPI:1487325668
Name:QUINONEZ, TRISTA MARIE (SAC-IT)
Entity type:Individual
Prefix:MRS
First Name:TRISTA
Middle Name:MARIE
Last Name:QUINONEZ
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-2648
Mailing Address - Country:US
Mailing Address - Phone:608-361-7200
Mailing Address - Fax:
Practice Address - Street 1:2240 PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-2648
Practice Address - Country:US
Practice Address - Phone:608-361-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19507-013101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)