Provider Demographics
NPI:1487078176
Name:HUERTA, MONIQUE
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:HUERTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1963 ANNANDALE WAY
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-3561
Mailing Address - Country:US
Mailing Address - Phone:909-519-9685
Mailing Address - Fax:
Practice Address - Street 1:1963 ANNANDALE WAY
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3561
Practice Address - Country:US
Practice Address - Phone:909-519-9685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-14
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA01-148465101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01-148465OtherCAS CERTIFICATION