Provider Demographics
NPI:1750325270
Name:QUEZADA, ANSELMO (MS)
Entity Type:Individual
Prefix:
First Name:ANSELMO
Middle Name:
Last Name:QUEZADA
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9814 HIGHLAND DR NE
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-3451
Mailing Address - Country:US
Mailing Address - Phone:509-765-9239
Mailing Address - Fax:509-765-1582
Practice Address - Street 1:840 E PLUM ST
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-1874
Practice Address - Country:US
Practice Address - Phone:509-765-9239
Practice Address - Fax:509-765-1582
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00054017101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health