Provider Demographics
NPI:1316416886
Name:ESTRADA, VANESSA
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:ESTRADA
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:PO BOX 151
Mailing Address - Street 2:
Mailing Address - City:TOME
Mailing Address - State:NM
Mailing Address - Zip Code:87060-0151
Mailing Address - Country:US
Mailing Address - Phone:505-389-9428
Mailing Address - Fax:
Practice Address - Street 1:3229 STATE HIGHWAY 47
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-7545
Practice Address - Country:US
Practice Address - Phone:505-389-9428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician