Provider Demographics
NPI:1710050786
Name:QUINN, ELAINE BONTJE (MA)
Entity Type:Individual
Prefix:MRS
First Name:ELAINE
Middle Name:BONTJE
Last Name:QUINN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:ELAINE
Other - Middle Name:MARIE
Other - Last Name:BONTJE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:2200 HAVASUPAI BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-3798
Mailing Address - Country:US
Mailing Address - Phone:928-505-6911
Mailing Address - Fax:928-505-6991
Practice Address - Street 1:2200 HAVASUPAI BLVD
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-3798
Practice Address - Country:US
Practice Address - Phone:928-505-6911
Practice Address - Fax:928-505-6991
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPL1715235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist