Provider Demographics
NPI:1912690900
Name:HUACUJA, KEILA
Entity type:Individual
Prefix:MS
First Name:KEILA
Middle Name:
Last Name:HUACUJA
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:PO BOX 5
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91747-0005
Mailing Address - Country:US
Mailing Address - Phone:626-917-1801
Mailing Address - Fax:
Practice Address - Street 1:1515 W CAMERON AVE STE 350
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2726
Practice Address - Country:US
Practice Address - Phone:626-337-8811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-26
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT149326106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist