Healthcare Provider Details

I. General information

NPI: 1053602714
Provider Name (Legal Business Name): LOURDES MINJARES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2011
Last Update Date: 03/04/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1902 ROYALTY DR STE 240-260
POMONA CA
91767-3030
US

IV. Provider business mailing address

815 COLORADO BLVD STE 300
LOS ANGELES CA
90041-1744
US

V. Phone/Fax

Practice location:
  • Phone: 909-865-8355
  • Fax:
Mailing address:
  • Phone: 323-543-2800
  • Fax: 323-978-1263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number124424
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: