Provider Demographics
NPI:1689286957
Name:TATE-QUINALTY, ETHIE M (OTR/L)
Entity Type:Individual
Prefix:
First Name:ETHIE
Middle Name:M
Last Name:TATE-QUINALTY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7016 SVL BOX
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-5107
Mailing Address - Country:US
Mailing Address - Phone:760-953-9267
Mailing Address - Fax:
Practice Address - Street 1:7898 CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-2597
Practice Address - Country:US
Practice Address - Phone:951-643-3699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT10656225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist