Healthcare Provider Details

I. General information

NPI: 1114347382
Provider Name (Legal Business Name): MAYRA QUEZADA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2014
Last Update Date: 04/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3569 LEXINGTON AVE
EL MONTE CA
91731-2607
US

IV. Provider business mailing address

6771 ORIZABA AVE
LONG BEACH CA
90805-1934
US

V. Phone/Fax

Practice location:
  • Phone: 626-453-3399
  • Fax:
Mailing address:
  • Phone: 310-714-2683
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT37417
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: