Basic Information
| Provider Information | |||||||||
| NPI: | 1558853499 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | HEAD | ||||||||
| FirstName: | MARCQUITTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 875 DERBYSHIRE RD APT 278 | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321173964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047482425 | ||||||||
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| Practice Location | |||||||||
| Address1: | 56 WATER ST | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320842887 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273644024 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2018 | ||||||||
| LastUpdateDate: | 03/31/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 222Q00000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist | 252Y00000X | Y | Agencies | Early Intervention Provider Agency |
ID Information
| ID | Type | State | Issuer | Description | 1283937 | 01 | FL | TEACHING CERTIFICATE | OTHER |