Provider Demographics
NPI:1033743448
Name:QUIROZ, FAVIOLA
Entity Type:Individual
Prefix:MISS
First Name:FAVIOLA
Middle Name:
Last Name:QUIROZ
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 1:22811 114TH AVE E
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98338-6720
Mailing Address - Country:US
Mailing Address - Phone:253-226-0525
Mailing Address - Fax:
Practice Address - Street 1:3808 S ANGELINE ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98118-1712
Practice Address - Country:US
Practice Address - Phone:253-285-4750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-25
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61039584101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACO61039584OtherSUBSTANCE USE DISORDER TRAINEE