Healthcare Provider Details

I. General information

NPI: 1215682380
Provider Name (Legal Business Name): ANTONIO DE JESUS QUEZADA LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2022
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 W REDLANDS BLVD STE B
REDLANDS CA
92373-4642
US

IV. Provider business mailing address

2736 GENEVIEVE ST
SAN BERNARDINO CA
92405-3516
US

V. Phone/Fax

Practice location:
  • Phone: 909-686-6233
  • Fax: 909-353-4985
Mailing address:
  • Phone: 909-894-8585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number130229
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: