Healthcare Provider Details

I. General information

NPI: 1295689610
Provider Name (Legal Business Name): EUSEBIO QUEZADA LIAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2026
Last Update Date: 02/23/2026
Certification Date: 02/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15650 N BLACK CANYON HWY STE B121
PHOENIX AZ
85053-4064
US

IV. Provider business mailing address

8002 W ROMA AVE
PHOENIX AZ
85033-2207
US

V. Phone/Fax

Practice location:
  • Phone: 480-649-3352
  • Fax: 480-649-3358
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLIAC-11384
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: