Provider Demographics
NPI:1215682380
Name:QUEZADA, ANTONIO DE JESUS (ACSW)
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:DE JESUS
Last Name:QUEZADA
Suffix:
Gender:M
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 W REDLANDS BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4642
Mailing Address - Country:US
Mailing Address - Phone:909-686-6233
Mailing Address - Fax:
Practice Address - Street 1:1625 SCHRADER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90028-6213
Practice Address - Country:US
Practice Address - Phone:323-993-7629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-17
Last Update Date:2025-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1302291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01536011OtherMEDI-CAL