Provider Demographics
NPI:1174965206
Name:QUEZADA, MAYRA LILIANA (PSYD)
Entity type:Individual
Prefix:DR
First Name:MAYRA
Middle Name:LILIANA
Last Name:QUEZADA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 LAWRENCE EXPY
Mailing Address - Street 2:PMB 952
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94085-4014
Mailing Address - Country:US
Mailing Address - Phone:408-475-3757
Mailing Address - Fax:
Practice Address - Street 1:530 LAWRENCE EXPY
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94085-4014
Practice Address - Country:US
Practice Address - Phone:408-475-3757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-17
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA31202103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program