Provider Demographics
NPI:1386007268
Name:QUINONES, MYRTHA
Entity Type:Individual
Prefix:
First Name:MYRTHA
Middle Name:
Last Name:QUINONES
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 1:11 SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-2213
Mailing Address - Country:US
Mailing Address - Phone:508-798-1900
Mailing Address - Fax:508-798-1914
Practice Address - Street 1:11 SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-2213
Practice Address - Country:US
Practice Address - Phone:508-798-1900
Practice Address - Fax:508-798-1914
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1316245319OtherMBHP