Provider Demographics
NPI:1346917564
Name:WILSON, QUINTA LUZESTHER
Entity Type:Individual
Prefix:
First Name:QUINTA
Middle Name:LUZESTHER
Last Name:WILSON
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 1:510 MCCORMICK DR STE U-W
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-3283
Mailing Address - Country:US
Mailing Address - Phone:410-595-5870
Mailing Address - Fax:
Practice Address - Street 1:510 MCCORMICK DR STE U-W
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-3283
Practice Address - Country:US
Practice Address - Phone:410-595-5870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-25
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician