Provider Demographics
NPI:1093881112
Name:EASTFIELD MING QUONG
Entity Type:Organization
Organization Name:EASTFIELD MING QUONG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PROGRAM MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:408-832-0832
Mailing Address - Street 1:209 LEMOS AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-5114
Mailing Address - Country:US
Mailing Address - Phone:831-421-9918
Mailing Address - Fax:
Practice Address - Street 1:209 LEMOS AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-5114
Practice Address - Country:US
Practice Address - Phone:831-421-9918
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20903251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA5480825OtherDRIVER'S LICENSE