Provider Demographics
NPI:1770178360
Name:QUINTANA BAEZ, MARIELIZ ENID
Entity type:Individual
Prefix:
First Name:MARIELIZ
Middle Name:ENID
Last Name:QUINTANA BAEZ
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:PO BOX 3703
Mailing Address - Street 2:
Mailing Address - City:SAN SEBASTIAN
Mailing Address - State:PR
Mailing Address - Zip Code:00685-3703
Mailing Address - Country:US
Mailing Address - Phone:787-374-2161
Mailing Address - Fax:
Practice Address - Street 1:BO GUATEMALA
Practice Address - Street 2:CARR 111 KM 16.8 INT
Practice Address - City:SAN SEBASTIAN
Practice Address - State:PR
Practice Address - Zip Code:00685
Practice Address - Country:US
Practice Address - Phone:787-374-2161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-04
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1479101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor