Provider Demographics
NPI:1770756801
Name:GARRETT, QUILLAN B II (MS CSW CSAC ICS)
Entity type:Individual
Prefix:
First Name:QUILLAN
Middle Name:B
Last Name:GARRETT
Suffix:II
Gender:M
Credentials:MS CSW CSAC ICS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2319 W CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53206-1919
Mailing Address - Country:US
Mailing Address - Phone:414-442-7720
Mailing Address - Fax:
Practice Address - Street 1:2319 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53206-1919
Practice Address - Country:US
Practice Address - Phone:414-442-7720
Practice Address - Fax:414-442-2167
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11522101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39383900Medicaid