Provider Demographics
NPI:1437535457
Name:ESTRADA-WIGGINS, ANA LISSETH
Entity Type:Individual
Prefix:
First Name:ANA
Middle Name:LISSETH
Last Name:ESTRADA-WIGGINS
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 1:14112 S KINGSLEY DR
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90249-3018
Mailing Address - Country:US
Mailing Address - Phone:310-217-7312
Mailing Address - Fax:
Practice Address - Street 1:14112 S KINGSLEY DR
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90249-3018
Practice Address - Country:US
Practice Address - Phone:310-217-7312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-31
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 390200000X
CA989061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program