Provider Demographics
NPI:1215218623
Name:LUIS QUERO, VIANNEY
Entity Type:Individual
Prefix:
First Name:VIANNEY
Middle Name:
Last Name:LUIS QUERO
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:PO BOX 9813
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92169-0813
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9246 LIGHTWAVE AVE STE 120
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-6411
Practice Address - Country:US
Practice Address - Phone:800-270-5016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-31
Last Update Date:2022-02-16
Deactivation Date:2021-12-30
Deactivation Code:
Reactivation Date:2022-02-16
Provider Licenses
StateLicense IDTaxonomies
390200000X, 101YM0800X
CA32751103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health