Healthcare Provider Details

I. General information

NPI: 1376922617
Provider Name (Legal Business Name): LOVINGLY QUITANIA PARK, PH.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2015
Last Update Date: 05/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1560 E CHEVY CHASE DR
GLENDALE CA
91206-4197
US

IV. Provider business mailing address

PO BOX 1292
LA CANADA CA
91012-5292
US

V. Phone/Fax

Practice location:
  • Phone: 818-800-8697
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY25525
License Number StateCA

VIII. Authorized Official

Name: DR. LOVINGLY QUITANIA PARK
Title or Position: NEUROPSYCHOLOGIST
Credential: PHD
Phone: 818-800-8697