Provider Demographics
NPI:1407068315
Name:QUINTELA-SMITH, REBECCA (MA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:QUINTELA-SMITH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13105 177TH ST N
Mailing Address - Street 2:
Mailing Address - City:MARINE ON SAINT CROIX
Mailing Address - State:MN
Mailing Address - Zip Code:55047-8615
Mailing Address - Country:US
Mailing Address - Phone:612-240-4203
Mailing Address - Fax:651-433-3162
Practice Address - Street 1:155 WABASHA ST S
Practice Address - Street 2:SUITE 120
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55107-1801
Practice Address - Country:US
Practice Address - Phone:651-221-0914
Practice Address - Fax:651-221-0785
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 3746103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN120798OtherUCARE
MN331ROOWOtherBLUE CROSS BLUE SHIELD MN
MN62-64313OtherUBH