Provider Demographics
NPI:1639575137
Name:QUINEIFORM LLC
Entity type:Organization
Organization Name:QUINEIFORM LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:QUINN
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:651-343-4800
Mailing Address - Street 1:8519 EAGLE POINT BLVD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:LAKE ELMO
Mailing Address - State:MN
Mailing Address - Zip Code:55042-8629
Mailing Address - Country:US
Mailing Address - Phone:651-343-4800
Mailing Address - Fax:877-992-0282
Practice Address - Street 1:8519 EAGLE POINT BLVD
Practice Address - Street 2:SUITE 150
Practice Address - City:LAKE ELMO
Practice Address - State:MN
Practice Address - Zip Code:55042-8629
Practice Address - Country:US
Practice Address - Phone:651-343-4800
Practice Address - Fax:877-992-0282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-10
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5493251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health