Basic Information
| Provider Information | |||||||||
| NPI: | 1841395415 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | QUEZADA | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | ADAIR | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CERT ADDICTIONS SPEC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BUTTERMAN | ||||||||
| OtherFirstName: | CAROLYN | ||||||||
| OtherMiddleName: | ADAIR | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 228 | ||||||||
| Address2: | |||||||||
| City: | ADIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 96006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302993286 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 441 NORTH MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ALTURAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 96101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302336312 | ||||||||
| FaxNumber: | 5302335311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 03069762 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.