Provider Demographics
NPI:1225493836
Name:FACUNDO, LETICIA
Entity Type:Individual
Prefix:MS
First Name:LETICIA
Middle Name:
Last Name:FACUNDO
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 1:1460 E HOLT AVE STE 166
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-5852
Mailing Address - Country:US
Mailing Address - Phone:909-865-0209
Mailing Address - Fax:909-865-0185
Practice Address - Street 1:11041 VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91731-2516
Practice Address - Country:US
Practice Address - Phone:626-442-4177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-24
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2588101YP2500X
CA7227101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional