Provider Demographics
NPI:1427176213
Name:QUINTANILLA, JUAN ANTONIO (MFT)
Entity type:Individual
Prefix:MR
First Name:JUAN
Middle Name:ANTONIO
Last Name:QUINTANILLA
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5588 N PALM AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93704-1913
Mailing Address - Country:US
Mailing Address - Phone:559-836-7825
Mailing Address - Fax:559-746-7212
Practice Address - Street 1:5588 N PALM AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93704-1913
Practice Address - Country:US
Practice Address - Phone:559-836-7825
Practice Address - Fax:559-746-7212
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF72871101YM0800X
CAIMF51969101YM0800X
CA85178106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health