Provider Demographics
NPI:1780166165
Name:QUIROZ, FERNANDO RODRIGUEZ JR
Entity type:Individual
Prefix:
First Name:FERNANDO
Middle Name:RODRIGUEZ
Last Name:QUIROZ
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25601 HEATHEROW CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-5020
Mailing Address - Country:US
Mailing Address - Phone:949-891-5020
Mailing Address - Fax:
Practice Address - Street 1:25601 HEATHEROW CIR
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-5020
Practice Address - Country:US
Practice Address - Phone:949-891-5020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-03
Last Update Date:2018-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY3448703103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst