Provider Demographics
NPI:1861160657
Name:ANCRUM, QIANA MONIQUE (MSW)
Entity type:Individual
Prefix:MS
First Name:QIANA
Middle Name:MONIQUE
Last Name:ANCRUM
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 W SEMINOLE BLVD APT 155
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-1271
Mailing Address - Country:US
Mailing Address - Phone:347-361-1962
Mailing Address - Fax:
Practice Address - Street 1:401 W SEMINOLE BLVD APT 155
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-1271
Practice Address - Country:US
Practice Address - Phone:347-361-1962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-06
Last Update Date:2021-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor