Healthcare Provider Details

I. General information

NPI: 1508265703
Provider Name (Legal Business Name): CARLOS G QUIJADA SR. MS, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2014
Last Update Date: 08/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 N DOUGLAS AVE
DOUGLAS AZ
85607-1019
US

IV. Provider business mailing address

2851 S AVENUE B # 4
YUMA AZ
85364-7726
US

V. Phone/Fax

Practice location:
  • Phone: 520-366-3133
  • Fax: 520-364-2770
Mailing address:
  • Phone: 928-376-0026
  • Fax: 928-782-2298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-14543
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: