Provider Demographics
NPI:1609300508
Name:QUINTANILLS, LYDIA (R1237331116)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:QUINTANILLS
Suffix:
Gender:F
Credentials:R1237331116
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8414 12 SAN VINCENTE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90250
Mailing Address - Country:US
Mailing Address - Phone:323-810-3153
Mailing Address - Fax:
Practice Address - Street 1:3756 SANTA ROSALIA DR SUITE 617
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008
Practice Address - Country:US
Practice Address - Phone:323-296-1840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-18
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1237331116101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)