Provider Demographics
NPI:1154072213
Name:CHAVEZ HERNANDEZ, LETICIA
Entity Type:Individual
Prefix:
First Name:LETICIA
Middle Name:
Last Name:CHAVEZ HERNANDEZ
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 1:528 COTTAGE ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3811
Mailing Address - Country:US
Mailing Address - Phone:503-583-8537
Mailing Address - Fax:
Practice Address - Street 1:528 COTTAGE ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3811
Practice Address - Country:US
Practice Address - Phone:503-583-8537
Practice Address - Fax:503-343-3331
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-11
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR8401106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty