Healthcare Provider Details

I. General information

NPI: 1285571729
Provider Name (Legal Business Name): QUEVA STAFORD
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2026
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 E JEFFERSON BLVD APT 109
LOS ANGELES CA
90011-6273
US

IV. Provider business mailing address

1044 E JEFFERSON BLVD APT 109
LOS ANGELES CA
90011-6273
US

V. Phone/Fax

Practice location:
  • Phone: 424-200-8834
  • Fax:
Mailing address:
  • Phone: 424-200-8834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: