Provider Demographics
NPI:1417420407
Name:FIESTA, LINDA (LCPC)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:FIESTA
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 CHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21403-3230
Mailing Address - Country:US
Mailing Address - Phone:443-604-1681
Mailing Address - Fax:
Practice Address - Street 1:104 FORBES ST STE 205
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-1598
Practice Address - Country:US
Practice Address - Phone:443-604-1681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-02
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC7804101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDLC7804OtherLICENSURE