Provider Demographics
NPI:1013219229
Name:QUEZADA, KIMBERLY (MS, LMFT 99748)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:QUEZADA
Suffix:
Gender:F
Credentials:MS, LMFT 99748
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4737
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:CA
Mailing Address - Zip Code:92325-4737
Mailing Address - Country:US
Mailing Address - Phone:714-654-2613
Mailing Address - Fax:
Practice Address - Street 1:460 S STODDARD AVE STE 1
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92401-2039
Practice Address - Country:US
Practice Address - Phone:909-882-7978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-19
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA99748106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist