Provider Demographics
NPI:1265867261
Name:ENRIQUEZ, ALEJANDRA
Entity Type:Individual
Prefix:
First Name:ALEJANDRA
Middle Name:
Last Name:ENRIQUEZ
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 1:855 N EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-2729
Mailing Address - Country:US
Mailing Address - Phone:909-983-2020
Mailing Address - Fax:909-983-6847
Practice Address - Street 1:855 N EUCLID AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762
Practice Address - Country:US
Practice Address - Phone:909-983-2020
Practice Address - Fax:909-983-6847
Is Sole Proprietor?:No
Enumeration Date:2013-09-09
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA823171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-1946482Medicaid