Healthcare Provider Details

I. General information

NPI: 1255521696
Provider Name (Legal Business Name): LAQUENTA MARZETT LONG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2007
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11175 AZUSA CT STE 110
RANCHO CUCAMONGA CA
91730-4933
US

IV. Provider business mailing address

11175 AZUSA CT STE 110
RANCHO CUCAMONGA CA
91730-4933
US

V. Phone/Fax

Practice location:
  • Phone: 909-987-8400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number53992
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: