Provider Demographics
NPI:1689032260
Name:RIVERA ESTRADA, LETICIA
Entity type:Individual
Prefix:
First Name:LETICIA
Middle Name:
Last Name:RIVERA ESTRADA
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 1:12 YURICK RD
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02492-2116
Mailing Address - Country:US
Mailing Address - Phone:787-469-2454
Mailing Address - Fax:
Practice Address - Street 1:12 YURICK ROAD
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02494-2203
Practice Address - Country:US
Practice Address - Phone:787-469-2454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-10
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1307576Medicaid
MAM18463OtherBLUE CROSS BLUE SHIELD
MA1303295Medicaid
MAM18463OtherBLUE CROSS BLUE SHIELD