Provider Demographics
NPI:1699470955
Name:QUESINBERRY, SHADOW
Entity type:Individual
Prefix:
First Name:SHADOW
Middle Name:
Last Name:QUESINBERRY
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 1:1420 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1470
Mailing Address - Country:US
Mailing Address - Phone:336-560-7878
Mailing Address - Fax:
Practice Address - Street 1:1420 PLAZA DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1470
Practice Address - Country:US
Practice Address - Phone:335-560-7878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician