Provider Demographics
NPI:1174010607
Name:QUIROZ, MELISSA SUE (MA, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:SUE
Last Name:QUIROZ
Suffix:
Gender:F
Credentials:MA, BCBA, LBA
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:MALLON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, BCBA, LBA
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:971 N GILBERT RD STE 101
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-3481
Practice Address - Country:US
Practice Address - Phone:480-559-8089
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2018-04-19
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBEH-000345103K00000X
AZBA-0345103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-17-28249OtherBCBA CERTIFICATE