Provider Demographics
NPI:1568501971
Name:NEIDHOLD, RAQUEL J (MS)
Entity Type:Individual
Prefix:
First Name:RAQUEL
Middle Name:J
Last Name:NEIDHOLD
Suffix:
Gender:F
Credentials:MS
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 74189
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-0189
Mailing Address - Country:US
Mailing Address - Phone:213-639-2661
Mailing Address - Fax:213-389-1987
Practice Address - Street 1:2500 WILSHIRE BLVD
Practice Address - Street 2:SUITE 704
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-4303
Practice Address - Country:US
Practice Address - Phone:213-639-2661
Practice Address - Fax:213-389-1987
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51513106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist