Provider Demographics
NPI:1740777929
Name:QUINN, REBECCA M
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:M
Last Name:QUINN
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 1:15955 NEW HALLS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-1298
Mailing Address - Country:US
Mailing Address - Phone:314-953-4991
Mailing Address - Fax:
Practice Address - Street 1:5323 VILLE MARIA LN
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-1143
Practice Address - Country:US
Practice Address - Phone:314-953-4991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-13
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0371900235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO465926608Medicaid