=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508265703
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARLOS G QUIJADA SR. MS, LPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2014
-----------------------------------------------------
Last Update Date | 08/14/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1701 N DOUGLAS AVE
-----------------------------------------------------
City | DOUGLAS
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85607-1019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-366-3133
-----------------------------------------------------
Fax | 520-364-2770
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2851 S AVENUE B # 4
-----------------------------------------------------
City | YUMA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85364-7726
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-376-0026
-----------------------------------------------------
Fax | 928-782-2298
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC-14543
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------