Provider Demographics
NPI:1598893968
Name:QUINN, MALLORY K (DT)
Entity Type:Individual
Prefix:MS
First Name:MALLORY
Middle Name:K
Last Name:QUINN
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10401 S. SANGAMON
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628
Mailing Address - Country:US
Mailing Address - Phone:773-776-3685
Mailing Address - Fax:
Practice Address - Street 1:3040 N. WILTON
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657
Practice Address - Country:US
Practice Address - Phone:773-296-8452
Practice Address - Fax:773-296-7281
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILMQ15380506P174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILMQ15380506POtherEARLY INTERVENTION PROVID