Provider Demographics
NPI:1609830066
Name:ENRIQUEZ, LYDIA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LYDIA
Middle Name:
Last Name:ENRIQUEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LYDIA
Other - Middle Name:
Other - Last Name:ENRIQUEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:10808 FOOTHILL BLVD STE 160
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-0601
Mailing Address - Country:US
Mailing Address - Phone:909-331-1744
Mailing Address - Fax:909-527-3112
Practice Address - Street 1:8002 HAVEN AVE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3047
Practice Address - Country:US
Practice Address - Phone:909-331-7440
Practice Address - Fax:909-527-3112
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA205281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20528OtherPROFESSIONAL LICENSE