Provider Demographics
NPI:1538903737
Name:QUINTANILLA, SELENA DEZIRAE
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:DEZIRAE
Last Name:QUINTANILLA
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 1:501 COUNTY ROAD 126
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-2416
Mailing Address - Country:US
Mailing Address - Phone:512-677-0959
Mailing Address - Fax:
Practice Address - Street 1:501 COUNTY ROAD 126
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-2416
Practice Address - Country:US
Practice Address - Phone:512-677-0959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-21
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician