Provider Demographics
NPI:1629699137
Name:ESTRELLADO, JOEL
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:
Last Name:ESTRELLADO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 COURAGE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-6717
Mailing Address - Country:US
Mailing Address - Phone:707-428-1131
Mailing Address - Fax:209-992-4092
Practice Address - Street 1:245 11TH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-3732
Practice Address - Country:US
Practice Address - Phone:415-355-0353
Practice Address - Fax:415-355-0353
Is Sole Proprietor?:No
Enumeration Date:2020-05-06
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247000000X
CA33851167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247000000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health Information
No167G00000XNursing Service ProvidersLicensed Psychiatric Technician