Provider Demographics
NPI:1821783382
Name:QUEEN, WITNEY
Entity Type:Individual
Prefix:
First Name:WITNEY
Middle Name:
Last Name:QUEEN
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 1:606 ALLENDE BND
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78748-4080
Mailing Address - Country:US
Mailing Address - Phone:708-308-9419
Mailing Address - Fax:
Practice Address - Street 1:1314 FERRIS AVE
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-1862
Practice Address - Country:US
Practice Address - Phone:469-242-0960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician