Basic Information
| Provider Information | |||||||||
| NPI: | 1902384761 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | QUINTOS | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | ATC LAT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 541 CHICORY LN | ||||||||
| Address2: | |||||||||
| City: | VALPARAISO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463858390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087681856 | ||||||||
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| Practice Location | |||||||||
| Address1: | 901 MACARTHUR BLVD | ||||||||
| Address2: | |||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463212901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198361600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2018 | ||||||||
| LastUpdateDate: | 08/03/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 36002322A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.