diff --git a/app/Services/Care/DemoTenantSeeder.php b/app/Services/Care/DemoTenantSeeder.php
index 263b598..6608535 100644
--- a/app/Services/Care/DemoTenantSeeder.php
+++ b/app/Services/Care/DemoTenantSeeder.php
@@ -456,6 +456,8 @@ class DemoTenantSeeder
     private function seedSpecialtyModules(Organization $organization, string $ownerRef): void
     {
         try {
+            // Activates dentistry (depts + stubs). When queue_integration_enabled and
+            // QUEUE_API_* are configured, SpecialtyModuleService creates real Queue counters.
             app(SpecialtyModuleService::class)->activate($organization->fresh(), $ownerRef, 'dentistry');
         } catch (\Throwable) {
             // Demo seed should not fail if Queue API is unreachable; settings flag remains.
diff --git a/app/Services/Care/ServiceQueuePresenter.php b/app/Services/Care/ServiceQueuePresenter.php
index 2389ab9..ea9ff7c 100644
--- a/app/Services/Care/ServiceQueuePresenter.php
+++ b/app/Services/Care/ServiceQueuePresenter.php
@@ -108,8 +108,13 @@ class ServiceQueuePresenter
             }
         }
 
-        $counters = $this->filterCounters($counters, $branchName, $context);
+        $stubCounterUuid = collect($stubs)
+            ->map(fn ($s) => (string) ($s['counter_uuid'] ?? ''))
+            ->first(fn ($uuid) => $uuid !== '');
+
+        $counters = $this->filterCounters($counters, $branchName, $context, $stubCounterUuid);
         $counterUuid = $preferredCounterUuid
+            ?: ($stubCounterUuid ?: '')
             ?: (string) ($counters[0]['uuid'] ?? '');
 
         if ($counterUuid !== '' && ! collect($counters)->contains(fn ($c) => ($c['uuid'] ?? '') === $counterUuid)) {
@@ -165,11 +170,21 @@ class ServiceQueuePresenter
      * @param  list<array<string, mixed>>  $counters
      * @return list<array<string, mixed>>
      */
-    protected function filterCounters(array $counters, ?string $branchName, string $context): array
-    {
-        $keywords = $this->keywordsFor($context);
+    protected function filterCounters(
+        array $counters,
+        ?string $branchName,
+        string $context,
+        ?string $preferredUuid = null,
+    ): array {
+        $all = collect($counters);
+        $filtered = $all;
 
-        $filtered = collect($counters);
+        if ($preferredUuid) {
+            $linked = $all->first(fn ($c) => ($c['uuid'] ?? '') === $preferredUuid);
+            if ($linked) {
+                return [$linked];
+            }
+        }
 
         if ($branchName) {
             $branchFiltered = $filtered->filter(function ($counter) use ($branchName) {
@@ -182,11 +197,16 @@ class ServiceQueuePresenter
             }
         }
 
+        $keywords = $this->keywordsFor($context);
         if ($keywords !== []) {
             $keywordFiltered = $filtered->filter(function ($counter) use ($keywords) {
+                $queueNames = collect($counter['queues'] ?? [])->map(function ($q) {
+                    return is_array($q) ? (string) ($q['name'] ?? '') : (string) $q;
+                })->implode(' ');
+
                 $haystack = strtolower(implode(' ', [
                     (string) ($counter['name'] ?? ''),
-                    collect($counter['queues'] ?? [])->pluck('name')->implode(' '),
+                    $queueNames,
                 ]));
 
                 foreach ($keywords as $keyword) {
diff --git a/app/Services/Care/SpecialtyModuleService.php b/app/Services/Care/SpecialtyModuleService.php
index 565155a..0869150 100644
--- a/app/Services/Care/SpecialtyModuleService.php
+++ b/app/Services/Care/SpecialtyModuleService.php
@@ -157,7 +157,23 @@ class SpecialtyModuleService
         $organization->update(['settings' => $settings]);
 
         if (data_get($organization->fresh()->settings, 'queue_integration_enabled') && $this->queue->configured()) {
-            $this->queue->syncSpecialtyQueueStubs($ownerRef, $queueStubs);
+            try {
+                $synced = $this->queue->syncSpecialtyQueueStubs($ownerRef, $queueStubs);
+                $settings = $organization->fresh()->settings ?? [];
+                $provisioning = is_array($settings['specialty_module_provisioning'] ?? null)
+                    ? $settings['specialty_module_provisioning']
+                    : [];
+                $provisioning[$key] = array_merge($provisioning[$key] ?? [], [
+                    'queues' => $synced,
+                ]);
+                $settings['specialty_module_provisioning'] = $provisioning;
+                $organization->update(['settings' => $settings]);
+            } catch (\Throwable $e) {
+                Log::warning('specialty_module.queue_sync_failed', [
+                    'key' => $key,
+                    'message' => $e->getMessage(),
+                ]);
+            }
         }
     }
 
@@ -185,8 +201,27 @@ class SpecialtyModuleService
         }
 
         $queues = is_array($record['queues'] ?? null) ? $record['queues'] : [];
-        foreach ($queues as $i => $queue) {
-            $queues[$i]['active'] = false;
+
+        if (
+            data_get($settings, 'queue_integration_enabled')
+            && $this->queue->configured()
+            && $queues !== []
+        ) {
+            try {
+                $queues = $this->queue->deactivateSpecialtyQueueStubs($ownerRef, $queues);
+            } catch (\Throwable $e) {
+                Log::warning('specialty_module.queue_deactivate_failed', [
+                    'key' => $key,
+                    'message' => $e->getMessage(),
+                ]);
+                foreach ($queues as $i => $queue) {
+                    $queues[$i]['active'] = false;
+                }
+            }
+        } else {
+            foreach ($queues as $i => $queue) {
+                $queues[$i]['active'] = false;
+            }
         }
 
         $provisioning[$key] = array_merge($record, [
@@ -246,8 +281,8 @@ class SpecialtyModuleService
     }
 
     /**
-     * Care-side queue stubs (branch-aware). Full counter creation lives in Queue admin;
-     * stubs document intended queues and feed embedded panels / future API sync.
+     * Care-side queue stubs (branch-aware). When Queue integration is enabled,
+     * activate() creates/links real Queue queues + counters and stores UUIDs here.
      *
      * @param  array<string, mixed>  $definition
      * @return list<array<string, mixed>>
@@ -263,8 +298,16 @@ class SpecialtyModuleService
             ->where('is_active', true)
             ->get();
 
+        $existingByBranch = collect(
+            data_get($organization->settings, "specialty_module_provisioning.{$key}.queues", [])
+        )->keyBy(fn ($q) => (string) ($q['branch_id'] ?? ''));
+
         $stubs = [];
         foreach ($branches as $branch) {
+            $prior = is_array($existingByBranch->get((string) $branch->id))
+                ? $existingByBranch->get((string) $branch->id)
+                : [];
+
             $stubs[] = [
                 'module' => $key,
                 'branch_id' => $branch->id,
@@ -273,6 +316,12 @@ class SpecialtyModuleService
                 'prefix' => (string) ($definition['queue_prefix'] ?? strtoupper(substr($key, 0, 3))),
                 'active' => true,
                 'synced' => false,
+                'queue_uuid' => $prior['queue_uuid'] ?? null,
+                'counter_uuid' => $prior['counter_uuid'] ?? null,
+                'queue_external_key' => $prior['queue_external_key']
+                    ?? "care:specialty:{$key}:queue:{$branch->id}",
+                'counter_external_key' => $prior['counter_external_key']
+                    ?? "care:specialty:{$key}:counter:{$branch->id}",
             ];
         }
 
diff --git a/app/Services/Queue/QueueClient.php b/app/Services/Queue/QueueClient.php
index 3ba0398..985f697 100644
--- a/app/Services/Queue/QueueClient.php
+++ b/app/Services/Queue/QueueClient.php
@@ -4,6 +4,7 @@ namespace App\Services\Queue;
 
 use Illuminate\Http\Client\RequestException;
 use Illuminate\Support\Facades\Http;
+use Illuminate\Support\Facades\Log;
 
 class QueueClient
 {
@@ -100,6 +101,79 @@ class QueueClient
         return (array) ($response->json('data') ?? []);
     }
 
+    /**
+     * @return list<array<string, mixed>>
+     */
+    public function branches(string $owner): array
+    {
+        $response = $this->http($owner)->get($this->base().'/branches');
+        $response->throw();
+
+        return (array) ($response->json('data') ?? []);
+    }
+
+    /**
+     * @param  array<string, mixed>  $payload
+     * @return array<string, mixed>
+     */
+    public function ensureBranch(string $owner, array $payload): array
+    {
+        $response = $this->http($owner)->post($this->base().'/branches', $payload);
+        $response->throw();
+
+        return (array) ($response->json('data') ?? []);
+    }
+
+    /**
+     * @param  array<string, mixed>  $payload
+     * @return array<string, mixed>
+     */
+    public function ensureQueue(string $owner, array $payload): array
+    {
+        $response = $this->http($owner)->post($this->base().'/queues', $payload);
+        $response->throw();
+
+        return (array) ($response->json('data') ?? []);
+    }
+
+    /**
+     * @param  array<string, mixed>  $payload
+     * @return array<string, mixed>
+     */
+    public function ensureCounter(string $owner, array $payload): array
+    {
+        $response = $this->http($owner)->post($this->base().'/counters', $payload);
+        $response->throw();
+
+        return (array) ($response->json('data') ?? []);
+    }
+
+    /**
+     * Soft-deactivate a Queue counter without destroying history.
+     *
+     * @return array<string, mixed>
+     */
+    public function updateCounter(string $owner, string $counterUuid, array $payload): array
+    {
+        $response = $this->http($owner)->patch($this->base().'/counters/'.$counterUuid, $payload);
+        $response->throw();
+
+        return (array) ($response->json('data') ?? []);
+    }
+
+    /**
+     * Soft-deactivate a Queue service queue without destroying history.
+     *
+     * @return array<string, mixed>
+     */
+    public function updateQueue(string $owner, string $queueUuid, array $payload): array
+    {
+        $response = $this->http($owner)->patch($this->base().'/queues/'.$queueUuid, $payload);
+        $response->throw();
+
+        return (array) ($response->json('data') ?? []);
+    }
+
     /**
      * @return array<string, mixed>
      */
@@ -124,8 +198,8 @@ class QueueClient
     }
 
     /**
-     * Best-effort specialty queue sync. Care integration API is read/console-only today,
-     * so stubs remain Care-side until Queue exposes create-queue for service tokens.
+     * Create or link real Queue queues/counters for Care specialty stubs.
+     * Idempotent via external_key (and Queue-side name+branch fallback).
      *
      * @param  list<array<string, mixed>>  $stubs
      * @return list<array<string, mixed>>
@@ -137,20 +211,128 @@ class QueueClient
         }
 
         try {
-            $existing = collect($this->counters($owner))
-                ->flatMap(fn ($c) => $c['queues'] ?? [])
-                ->map(fn ($q) => strtolower((string) ($q['name'] ?? '')))
-                ->filter()
-                ->all();
+            if (! $this->isLinked($owner)) {
+                return $stubs;
+            }
         } catch (\Throwable) {
             return $stubs;
         }
 
         foreach ($stubs as $i => $stub) {
-            $name = strtolower((string) ($stub['name'] ?? ''));
-            $stubs[$i]['synced'] = $name !== '' && in_array($name, $existing, true);
+            if (! ($stub['active'] ?? true)) {
+                continue;
+            }
+
+            try {
+                $stubs[$i] = $this->ensureSpecialtyStub($owner, $stub);
+            } catch (\Throwable $e) {
+                Log::warning('queue.specialty_stub_sync_failed', [
+                    'owner' => $owner,
+                    'stub' => $stub['name'] ?? null,
+                    'branch' => $stub['branch_name'] ?? null,
+                    'message' => $e->getMessage(),
+                ]);
+                $stubs[$i]['synced'] = false;
+            }
         }
 
         return $stubs;
     }
+
+    /**
+     * Soft-deactivate Queue resources linked on Care stubs (leaves history intact).
+     *
+     * @param  list<array<string, mixed>>  $stubs
+     * @return list<array<string, mixed>>
+     */
+    public function deactivateSpecialtyQueueStubs(string $owner, array $stubs): array
+    {
+        if (! $this->configured() || $stubs === []) {
+            return $stubs;
+        }
+
+        foreach ($stubs as $i => $stub) {
+            try {
+                if (! empty($stub['counter_uuid'])) {
+                    $this->updateCounter($owner, (string) $stub['counter_uuid'], ['is_active' => false]);
+                }
+                if (! empty($stub['queue_uuid'])) {
+                    $this->updateQueue($owner, (string) $stub['queue_uuid'], ['is_active' => false]);
+                }
+            } catch (\Throwable $e) {
+                Log::warning('queue.specialty_stub_deactivate_failed', [
+                    'owner' => $owner,
+                    'counter_uuid' => $stub['counter_uuid'] ?? null,
+                    'queue_uuid' => $stub['queue_uuid'] ?? null,
+                    'message' => $e->getMessage(),
+                ]);
+            }
+
+            $stubs[$i]['active'] = false;
+        }
+
+        return $stubs;
+    }
+
+    /**
+     * @param  array<string, mixed>  $stub
+     * @return array<string, mixed>
+     */
+    protected function ensureSpecialtyStub(string $owner, array $stub): array
+    {
+        $branchName = trim((string) ($stub['branch_name'] ?? ''));
+        $name = trim((string) ($stub['name'] ?? ''));
+        $prefix = trim((string) ($stub['prefix'] ?? 'A'));
+        $module = (string) ($stub['module'] ?? 'specialty');
+        $careBranchId = (string) ($stub['branch_id'] ?? '0');
+
+        if ($branchName === '' || $name === '') {
+            $stub['synced'] = false;
+
+            return $stub;
+        }
+
+        $queueKey = (string) ($stub['queue_external_key'] ?? "care:specialty:{$module}:queue:{$careBranchId}");
+        $counterKey = (string) ($stub['counter_external_key'] ?? "care:specialty:{$module}:counter:{$careBranchId}");
+
+        try {
+            $this->ensureBranch($owner, ['name' => $branchName]);
+        } catch (RequestException $e) {
+            // Free Queue plans may already be at branch cap — continue if branch already exists.
+            if ($e->response?->status() !== 422) {
+                throw $e;
+            }
+            $existing = collect($this->branches($owner))->first(
+                fn ($b) => strcasecmp((string) ($b['name'] ?? ''), $branchName) === 0
+            );
+            if (! $existing) {
+                throw $e;
+            }
+        }
+
+        $queue = $this->ensureQueue($owner, [
+            'name' => $name,
+            'prefix' => $prefix !== '' ? $prefix : 'A',
+            'branch_name' => $branchName,
+            'strategy' => 'fifo',
+            'external_key' => $queueKey,
+            'is_active' => true,
+        ]);
+
+        $counter = $this->ensureCounter($owner, [
+            'name' => $name.' counter',
+            'branch_name' => $branchName,
+            'queue_uuids' => array_values(array_filter([(string) ($queue['uuid'] ?? '')])),
+            'external_key' => $counterKey,
+            'is_active' => true,
+        ]);
+
+        $stub['queue_external_key'] = $queueKey;
+        $stub['counter_external_key'] = $counterKey;
+        $stub['queue_uuid'] = $queue['uuid'] ?? null;
+        $stub['counter_uuid'] = $counter['uuid'] ?? null;
+        $stub['synced'] = ! empty($stub['queue_uuid']) && ! empty($stub['counter_uuid']);
+
+        return $stub;
+    }
 }
diff --git a/tests/Feature/CareSpecialtyModulesTest.php b/tests/Feature/CareSpecialtyModulesTest.php
index cc31d60..f237c38 100644
--- a/tests/Feature/CareSpecialtyModulesTest.php
+++ b/tests/Feature/CareSpecialtyModulesTest.php
@@ -85,6 +85,134 @@ class CareSpecialtyModulesTest extends TestCase
         $this->assertSame($this->branch->id, $stubs[0]['branch_id']);
     }
 
+    public function test_activating_with_queue_integration_creates_real_counters(): void
+    {
+        config([
+            'care.queue.api_url' => 'https://queue.test/api/v1',
+            'care.queue.api_key' => 'care-test-key',
+        ]);
+
+        $this->organization->update([
+            'settings' => array_merge($this->organization->settings ?? [], [
+                'queue_integration_enabled' => true,
+            ]),
+        ]);
+
+        $queueUuid = 'aaaaaaaa-aaaa-aaaa-aaaa-aaaaaaaaaaaa';
+        $counterUuid = 'bbbbbbbb-bbbb-bbbb-bbbb-bbbbbbbbbbbb';
+
+        Http::fake([
+            'https://queue.test/api/v1/integrations/status*' => Http::response([
+                'data' => [
+                    'provisioned' => true,
+                    'integrations' => ['care' => true],
+                ],
+            ], 200),
+            'https://queue.test/api/v1/branches*' => Http::sequence()
+                ->push(['data' => ['id' => 1, 'name' => 'Main', 'is_active' => true]], 200)
+                ->push(['data' => ['id' => 1, 'name' => 'Main', 'is_active' => true]], 200),
+            'https://queue.test/api/v1/queues*' => Http::response([
+                'data' => [
+                    'uuid' => $queueUuid,
+                    'name' => 'Dentistry',
+                    'prefix' => 'DEN',
+                    'external_key' => 'care:specialty:dentistry:queue:'.$this->branch->id,
+                ],
+            ], 201),
+            'https://queue.test/api/v1/counters*' => Http::response([
+                'data' => [
+                    'uuid' => $counterUuid,
+                    'name' => 'Dentistry counter',
+                    'branch' => 'Main',
+                    'queues' => [['uuid' => $queueUuid, 'name' => 'Dentistry']],
+                ],
+            ], 201),
+        ]);
+
+        app(SpecialtyModuleService::class)->activate(
+            $this->organization->fresh(),
+            $this->owner->public_id,
+            'dentistry',
+        );
+
+        $this->organization->refresh();
+        $stub = data_get($this->organization->settings, 'specialty_module_provisioning.dentistry.queues.0');
+        $this->assertTrue((bool) ($stub['synced'] ?? false));
+        $this->assertSame($queueUuid, $stub['queue_uuid'] ?? null);
+        $this->assertSame($counterUuid, $stub['counter_uuid'] ?? null);
+
+        Http::assertSent(function ($request) {
+            return $request->method() === 'POST'
+                && str_contains($request->url(), '/queues')
+                && ($request['external_key'] ?? null) === 'care:specialty:dentistry:queue:'.$this->branch->id;
+        });
+    }
+
+    public function test_reactivation_is_idempotent_for_queue_external_keys(): void
+    {
+        config([
+            'care.queue.api_url' => 'https://queue.test/api/v1',
+            'care.queue.api_key' => 'care-test-key',
+        ]);
+
+        $this->organization->update([
+            'settings' => array_merge($this->organization->settings ?? [], [
+                'queue_integration_enabled' => true,
+                'specialty_module_provisioning' => [
+                    'dentistry' => [
+                        'active' => false,
+                        'queues' => [[
+                            'module' => 'dentistry',
+                            'branch_id' => $this->branch->id,
+                            'branch_name' => 'Main',
+                            'name' => 'Dentistry',
+                            'prefix' => 'DEN',
+                            'active' => false,
+                            'synced' => true,
+                            'queue_uuid' => 'aaaaaaaa-aaaa-aaaa-aaaa-aaaaaaaaaaaa',
+                            'counter_uuid' => 'bbbbbbbb-bbbb-bbbb-bbbb-bbbbbbbbbbbb',
+                            'queue_external_key' => 'care:specialty:dentistry:queue:'.$this->branch->id,
+                            'counter_external_key' => 'care:specialty:dentistry:counter:'.$this->branch->id,
+                        ]],
+                    ],
+                ],
+            ]),
+        ]);
+
+        Http::fake([
+            'https://queue.test/api/v1/integrations/status*' => Http::response([
+                'data' => ['provisioned' => true, 'integrations' => ['care' => true]],
+            ], 200),
+            'https://queue.test/api/v1/branches*' => Http::response([
+                'data' => ['id' => 1, 'name' => 'Main', 'is_active' => true],
+            ], 200),
+            'https://queue.test/api/v1/queues*' => Http::response([
+                'data' => [
+                    'uuid' => 'aaaaaaaa-aaaa-aaaa-aaaa-aaaaaaaaaaaa',
+                    'name' => 'Dentistry',
+                    'external_key' => 'care:specialty:dentistry:queue:'.$this->branch->id,
+                ],
+            ], 200),
+            'https://queue.test/api/v1/counters*' => Http::response([
+                'data' => [
+                    'uuid' => 'bbbbbbbb-bbbb-bbbb-bbbb-bbbbbbbbbbbb',
+                    'name' => 'Dentistry counter',
+                ],
+            ], 200),
+        ]);
+
+        app(SpecialtyModuleService::class)->activate(
+            $this->organization->fresh(),
+            $this->owner->public_id,
+            'dentistry',
+        );
+
+        $this->organization->refresh();
+        $stub = data_get($this->organization->settings, 'specialty_module_provisioning.dentistry.queues.0');
+        $this->assertSame('care:specialty:dentistry:queue:'.$this->branch->id, $stub['queue_external_key']);
+        $this->assertSame('aaaaaaaa-aaaa-aaaa-aaaa-aaaaaaaaaaaa', $stub['queue_uuid']);
+    }
+
     public function test_deactivating_hides_department_without_deleting(): void
     {
         Http::fake();