Basic Information
| Provider Information | |||||||||
| NPI: | 1407289135 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | QUINTEROS | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | CARLOS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11162 RESEDA BLVD | ||||||||
| Address2: | |||||||||
| City: | PORTER RANCH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913262501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188258918 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6305 WOODMAN AVE | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914012346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189016376 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2013 | ||||||||
| LastUpdateDate: | 05/08/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 105350 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.