Provider Demographics
NPI:1073384921
Name:ESTRADA, JOHN ANSELMO
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ANSELMO
Last Name:ESTRADA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 GRANDE BLVD SE STE B
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1695
Mailing Address - Country:US
Mailing Address - Phone:505-218-6383
Mailing Address - Fax:888-514-6652
Practice Address - Street 1:2200 GRANDE BLVD SE STE B
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1695
Practice Address - Country:US
Practice Address - Phone:505-218-6383
Practice Address - Fax:888-514-6652
Is Sole Proprietor?:No
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician