Provider Demographics
NPI:1639485717
Name:QUINTANILLA, LEAH BETH (LMSW)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:BETH
Last Name:QUINTANILLA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:BETH
Other - Last Name:HOUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-486-6790
Mailing Address - Fax:
Practice Address - Street 1:1202 W OAK ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-2155
Practice Address - Country:US
Practice Address - Phone:616-754-4685
Practice Address - Fax:616-754-9883
Is Sole Proprietor?:No
Enumeration Date:2010-08-26
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010924901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical