Provider Demographics
NPI:1528377207
Name:QUEZADA, CONNIE (LAC)
Entity type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:
Last Name:QUEZADA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3004 MEDICAL ARTS ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-3305
Mailing Address - Country:US
Mailing Address - Phone:512-236-1141
Mailing Address - Fax:512-236-1141
Practice Address - Street 1:3004 MEDICAL ARTS ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-3305
Practice Address - Country:US
Practice Address - Phone:512-236-1141
Practice Address - Fax:512-236-1141
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-29
Last Update Date:2010-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT038682225700000X
TXAC01203171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist