Provider Demographics
NPI:1407476419
Name:QUINTANA, MICHALENE
Entity Type:Individual
Prefix:
First Name:MICHALENE
Middle Name:
Last Name:QUINTANA
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 1:2600 PALMILLA RD NW
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-4864
Mailing Address - Country:US
Mailing Address - Phone:505-295-2707
Mailing Address - Fax:
Practice Address - Street 1:2600 PALMILLA RD NW
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-4864
Practice Address - Country:US
Practice Address - Phone:505-295-2707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-20
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NM1-22-62857103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician