Provider Demographics
NPI:1164762845
Name:AMEZQUITA, PRISCILLA S
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:S
Last Name:AMEZQUITA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 W 6TH ST
Mailing Address - Street 2:SUITE 230
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-3316
Mailing Address - Country:US
Mailing Address - Phone:310-833-3135
Mailing Address - Fax:
Practice Address - Street 1:222 W 6TH ST
Practice Address - Street 2:SUITE 230
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-3316
Practice Address - Country:US
Practice Address - Phone:310-833-3135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-18
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW853381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical