Provider Demographics
NPI:1518405893
Name:RONQUILLO, AUDREY
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:RONQUILLO
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 1:800 FERRARI LN
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91710
Mailing Address - Country:US
Mailing Address - Phone:909-484-2848
Mailing Address - Fax:
Practice Address - Street 1:800 FERRARI LN
Practice Address - Street 2:SUITE 100
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91710
Practice Address - Country:US
Practice Address - Phone:909-484-2848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-07
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3877448106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician