Provider Demographics
NPI:1497091185
Name:FERNANDEZ, LETICIA VICTORIA
Entity Type:Individual
Prefix:
First Name:LETICIA
Middle Name:VICTORIA
Last Name:FERNANDEZ
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 1:8640 SE CAUSEY AVE
Mailing Address - Street 2:APT R201
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086-7599
Mailing Address - Country:US
Mailing Address - Phone:512-731-2335
Mailing Address - Fax:
Practice Address - Street 1:9830 NE CASCADES PKWY
Practice Address - Street 2:STE 200
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-6832
Practice Address - Country:US
Practice Address - Phone:512-731-2335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-27
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities