Provider Demographics
NPI:1568635613
Name:QUINTANILLA, ALEX BALMORE (LCSW 84870)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:BALMORE
Last Name:QUINTANILLA
Suffix:
Gender:M
Credentials:LCSW 84870
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 W KIRBY AVE UNIT 306
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-5507
Mailing Address - Country:US
Mailing Address - Phone:217-615-0350
Mailing Address - Fax:
Practice Address - Street 1:44 E MAIN ST STE 406
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3649
Practice Address - Country:US
Practice Address - Phone:217-615-0350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA848701041C0700X
IL149.0234301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical