Provider Demographics
NPI:1760579197
Name:QUINN, MITTIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MITTIE
Middle Name:
Last Name:QUINN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3925 OLD LEE HWY
Mailing Address - Street 2:SUITE 52A
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2426
Mailing Address - Country:US
Mailing Address - Phone:703-385-7575
Mailing Address - Fax:703-385-7578
Practice Address - Street 1:3925 OLD LEE HWY
Practice Address - Street 2:SUITE 52A
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2426
Practice Address - Country:US
Practice Address - Phone:703-385-7575
Practice Address - Fax:703-385-7578
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003340101YM0800X
VA0803000080103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health