Provider Demographics
NPI:1124602610
Name:QUINTANA, ANTONIO JORGE
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:JORGE
Last Name:QUINTANA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2213 NW 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33993-4139
Mailing Address - Country:US
Mailing Address - Phone:786-803-9360
Mailing Address - Fax:
Practice Address - Street 1:2620 PIERCE ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-3827
Practice Address - Country:US
Practice Address - Phone:786-803-9360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-10
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ535010904450OtherDL