Basic Information
Provider Information | |||||||||
NPI: | 1851471916 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PRADA-QUAN | ||||||||
FirstName: | GLORIA | ||||||||
MiddleName: | CECILIA | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | L.C.S.W. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4001 INGLEWOOD AVE | ||||||||
Address2: | SUITE # 101-330 | ||||||||
City: | REDONDO BEACH | ||||||||
State: | CA | ||||||||
PostalCode: | 902781112 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3105297043 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 19231 VICTORY BLVD | ||||||||
Address2: | SUITE # 110 | ||||||||
City: | RESEDA | ||||||||
State: | CA | ||||||||
PostalCode: | 91335 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8187084500 | ||||||||
FaxNumber: | 8186541956 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/16/2006 | ||||||||
LastUpdateDate: | 04/28/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/28/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | LCS18653 | CA | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 1041C0700X | LCS18653 | CA | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.