Provider Demographics
NPI:1669629655
Name:QUIROGA, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:QUIROGA
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:PO BOX 982
Mailing Address - Street 2:
Mailing Address - City:LA VETA
Mailing Address - State:CO
Mailing Address - Zip Code:81055-0982
Mailing Address - Country:US
Mailing Address - Phone:719-742-0219
Mailing Address - Fax:
Practice Address - Street 1:101 N 2ND ST
Practice Address - Street 2:
Practice Address - City:RATON
Practice Address - State:NM
Practice Address - Zip Code:87740-3803
Practice Address - Country:US
Practice Address - Phone:505-445-7090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-21
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM329265103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool