Provider Demographics
NPI:1366115925
Name:MARQUINA, IRIDIAN RAFAELA
Entity type:Individual
Prefix:
First Name:IRIDIAN
Middle Name:RAFAELA
Last Name:MARQUINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3932 MILLWOOD LN NW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-2623
Mailing Address - Country:US
Mailing Address - Phone:770-771-2743
Mailing Address - Fax:
Practice Address - Street 1:3775 VENTURE DR STE M101
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-5217
Practice Address - Country:US
Practice Address - Phone:470-610-4222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-29
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GABACB702046106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician