Provider Demographics
NPI:1497300180
Name:LE, LAURA ESTELA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ESTELA
Last Name:LE
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 1:2211 KATHRYN AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-6325
Mailing Address - Country:US
Mailing Address - Phone:909-764-1550
Mailing Address - Fax:
Practice Address - Street 1:8350 ARCHILBALD AVE STE 110
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730
Practice Address - Country:US
Practice Address - Phone:858-264-5858
Practice Address - Fax:858-649-6012
Is Sole Proprietor?:No
Enumeration Date:2019-08-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician