Provider Demographics
NPI:1689150443
Name:AVILEZ, QUETZALLI
Entity Type:Individual
Prefix:MS
First Name:QUETZALLI
Middle Name:
Last Name:AVILEZ
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 1:1529 GRAND AVE STE A
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-2464
Mailing Address - Country:US
Mailing Address - Phone:760-798-0299
Mailing Address - Fax:760-798-0399
Practice Address - Street 1:1529 GRAND AVE STE A
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-2464
Practice Address - Country:US
Practice Address - Phone:760-798-0299
Practice Address - Fax:760-798-0399
Is Sole Proprietor?:No
Enumeration Date:2018-07-16
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1177311041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical