Provider Demographics
NPI:1003354440
Name:FLORES, LETICIA ADRIANA
Entity Type:Individual
Prefix:
First Name:LETICIA
Middle Name:ADRIANA
Last Name:FLORES
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 BENJAMIN RD
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01602-4155
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:340 MAIN ST
Practice Address - Street 2:SUITE 819
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1604
Practice Address - Country:US
Practice Address - Phone:508-752-3969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-06
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS97328912101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health