Provider Demographics
NPI:1073206975
Name:DESIRED CHANGE THERAPEUTIC SOLUTIONS A LICENSED CLINICAL SOCIAL WORKER
Entity Type:Organization
Organization Name:DESIRED CHANGE THERAPEUTIC SOLUTIONS A LICENSED CLINICAL SOCIAL WORKER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DESERAE
Authorized Official - Middle Name:
Authorized Official - Last Name:QUEZADA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:909-609-6078
Mailing Address - Street 1:14050 CHERRY AVE.
Mailing Address - Street 2:STE R #1103
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92337
Mailing Address - Country:US
Mailing Address - Phone:909-609-6078
Mailing Address - Fax:
Practice Address - Street 1:822 S BREDEN LN
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-7829
Practice Address - Country:US
Practice Address - Phone:909-609-6078
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-29
Last Update Date:2023-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty