Provider Demographics
NPI:1306410915
Name:WHITE, LETICIA PERALTA
Entity Type:Individual
Prefix:
First Name:LETICIA
Middle Name:PERALTA
Last Name:WHITE
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 1:1720 S AMPHLETT BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-2710
Mailing Address - Country:US
Mailing Address - Phone:650-931-6300
Mailing Address - Fax:
Practice Address - Street 1:1720 S AMPHLETT BLVD STE 110
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-2710
Practice Address - Country:US
Practice Address - Phone:650-931-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-18
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician