Provider Demographics
NPI:1265279079
Name:CHACON QUINTERO, LILLIAM COROMOTO
Entity type:Individual
Prefix:
First Name:LILLIAM
Middle Name:COROMOTO
Last Name:CHACON QUINTERO
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 1:1301 ST TROPEZ CIR APT 2108
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-3013
Mailing Address - Country:US
Mailing Address - Phone:754-262-6798
Mailing Address - Fax:
Practice Address - Street 1:1301 ST TROPEZ CIR APT 2108
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326-3013
Practice Address - Country:US
Practice Address - Phone:754-262-6798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician