Provider Demographics
NPI:1992375257
Name:QUINTANA DAVILA, LIEPZIG
Entity Type:Individual
Prefix:
First Name:LIEPZIG
Middle Name:
Last Name:QUINTANA DAVILA
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 1:723 SW 99TH COURT CIR
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33174-1996
Mailing Address - Country:US
Mailing Address - Phone:786-486-0852
Mailing Address - Fax:
Practice Address - Street 1:723 SW 99TH COURT CIR
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33174-1996
Practice Address - Country:US
Practice Address - Phone:786-486-0852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110497800Medicaid