Basic Information
| Provider Information | |||||||||
| NPI: | 1114347382 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | QUEZADA | ||||||||
| FirstName: | MAYRA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6771 ORIZABA AVE | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908051934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107142683 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3569 LEXINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | EL MONTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917312607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264533399 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2014 | ||||||||
| LastUpdateDate: | 04/28/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 167G00000X | PT37417 | CA | Y | Nursing Service Providers | Licensed Psychiatric Technician |
No ID Information.