Basic Information
| Provider Information | |||||||||
| NPI: | 1427597038 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | QUIALA | ||||||||
| FirstName: | KENYA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2337 LILY PAD LN | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347433653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7875319119 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3201 BUDINGER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347697203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079102941 | ||||||||
| FaxNumber: | 8884777678 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2017 | ||||||||
| LastUpdateDate: | 02/15/2017 | ||||||||
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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 | 104100000X | 11360 | PR | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.