Provider Demographics
NPI:1639832116
Name:ESTRADA, GUSTAVO
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:ESTRADA
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 1:1229 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-1419
Mailing Address - Country:US
Mailing Address - Phone:509-393-8158
Mailing Address - Fax:
Practice Address - Street 1:246 N MISSION ST
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-2004
Practice Address - Country:US
Practice Address - Phone:509-293-8116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWDL2BS4G013B106S00000X, 103K00000X
106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst