Provider Demographics
NPI:1598151839
Name:QUINONES, IDALLAS
Entity Type:Individual
Prefix:
First Name:IDALLAS
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 1:3175 CARRSVILLE CT
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-1770
Mailing Address - Country:US
Mailing Address - Phone:941-894-5258
Mailing Address - Fax:
Practice Address - Street 1:3175 CARRSVILLE CT
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63139-1770
Practice Address - Country:US
Practice Address - Phone:941-894-5258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-14
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019030663103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst