Provider Demographics
NPI:1609630284
Name:ESTRADA, ANTONIETTA (MC)
Entity Type:Individual
Prefix:MISS
First Name:ANTONIETTA
Middle Name:
Last Name:ESTRADA
Suffix:
Gender:F
Credentials:MC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 N TREKELL RD STE A
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-1770
Mailing Address - Country:US
Mailing Address - Phone:520-836-1029
Mailing Address - Fax:520-836-6733
Practice Address - Street 1:1901 N TREKELL RD STE A
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-1770
Practice Address - Country:US
Practice Address - Phone:520-836-1029
Practice Address - Fax:520-836-6733
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-13
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC6013261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)