Provider Demographics
NPI:1801910252
Name:QUEBLES, IRINA (PSYD ABPP)
Entity type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:QUEBLES
Suffix:
Gender:F
Credentials:PSYD ABPP
Other - Prefix:
Other - First Name:IRINA
Other - Middle Name:
Other - Last Name:FERNANDEZ-QUEBLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4650 SUNSET BLVD, MS#53
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90207
Mailing Address - Country:US
Mailing Address - Phone:323-361-2350
Mailing Address - Fax:
Practice Address - Street 1:4650 SUNSET BLVD, MS #53
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90207
Practice Address - Country:US
Practice Address - Phone:323-361-7723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA22023103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACH62401OtherPROVIDER NUMBER