Provider Demographics
NPI:1801501317
Name:QUEEN, TEQUITA (MT)
Entity type:Individual
Prefix:
First Name:TEQUITA
Middle Name:
Last Name:QUEEN
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:969 TASKFORCE DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-7117
Mailing Address - Country:US
Mailing Address - Phone:800-495-9128
Mailing Address - Fax:
Practice Address - Street 1:969 TASKFORCE DR
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-7117
Practice Address - Country:US
Practice Address - Phone:800-495-9128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019014575225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist